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Industry Services Division County <br /> 4822 Madison Yards Way Burnett <br /> Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> j P.O.Box 7302 S RN-,9.2—146 t,10(438 <br /> Madison,WI 53707 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary 30050 Shaw d r <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Stephen & Dawn Nelson 07-032-2-41-15-15-515-476-045000 <br /> Property Owner's Mailing Address Property Location <br /> 5168 Par Lane NW Govt.Lot <br /> City,State Zip Code Phone Number <br /> Rochester MN 55901 507-261-8577 1, /, Section 27 <br /> II.Type of Building(check all that apply) Lot# T41 N R 15 E of <br /> D1 or 2 Family Dwelling-Number of Bedrooms 4 35 Subdivision Name <br /> Block# MINNEWAUKON PARK ASSESSORS PLAT LOT 35 <br /> [Public/Commercial-Describe Use <br /> any of <br /> ❑State Owned-Describe Use CSM Number Village of <br /> (Town of SWISS <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if <br /> applicable.) <br /> A. ❑New System Replacement System ❑Other Modification to Existing System(explain) Additional Pretreatment Unit(explain) <br /> B. Holding Tank Din-Ground IJAt-Grade Mound Individual Site Design ]Other Type(explain) <br /> (conventional) <br /> C. Renewal Before O Revision }Change of Plumber Dfransfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(s0 System Elevation <br /> 600 .7 857.14 904 87.5-81.5 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units U $ <br /> New Tanks Existing Tanks a, 2 <br /> - c) in '•n u, C7 0.. <br /> Septic or Holding Tank x 1250 1 Wieser I ✓ I I I l <br /> Dosing Chamber I EJ <br /> V.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber'• ture MP/MPRS Number Business Phone Number <br /> Luke Schmitz 884121 715-520-2434 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 160 Shell Lake WI 548 <br /> VI.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee p Date Issued Is m Ag t Signa <br /> ❑Owner Given Reason for Denial $376`'' LI f X(?) � • <br /> Conditions of Approval/Reasons or Di pproval <br /> omee+ <br /> TIVE [1 IE <br /> APR 19 2022 U <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/2 x 1.1 inc+ta in size ` <br /> '? 43 I Burnett County <br /> SBD-6398(R.02/22) 3� €_, Land Services Department <br />