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3°���40 County <br /> <° r �li Industry Services Division Burnett <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 SAty--at `Asir Neu) (444,4OO <br /> Madison,WI 53707-7162 <br /> IbPos(40, %r Z..i5g 41119 :7--1 <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 <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. 4730 Bertram Rd. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Jeff and Gayle Sprinkel 07-014-2-38-15-09-5 05-006-018000 I 4y <br /> v <br /> Property Owner's Mailing Address Property Location <br /> 2636 16'"Ave.South <br /> Govt.Lot 5+6 <br /> City,State Zip Code Phone Number '/a, '/<, Section 9 <br /> Minneapolis,MN 55407 612-202-1554cle one) <br /> T38N ; R15Eo/W) <br /> II.Type of Building(check all that apply) Lot# C/ <br /> El1 or 2 Family Dwelling-Number of Bedrooms 3 8�. 2 Subdivision Name <br /> Na <br /> ❑Public/Commercial-Describe Use Block# <br /> Na ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number CI Village of <br /> Vol. 13 Page 138 ® Town of LaFollette <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) _ <br /> A. 0 New System ® Replacement System 0 Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> I <br /> B. 0 Permit Renewal ❑ Permit Revision 0 Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ® Non-Pressurized In-Ground ❑ Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank ®Other Dispersal Component(explain) Lift ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 Rate(gpdsf) 643 Eisa of 660 C-1=100.30 C-2=100.00' <br /> .7 C-3=99.56' <br /> VI.Tank Info Capacity in <br /> :' a o <br /> Gallons Total #of Manufacturer ,9 ct U > " <br /> Gallons Units o .. g <br /> New Tanks Existing Tanks a U in ,, vz w C7 a, <br /> Septic or Holding Tank 1000 1000 1 Wieser Concrete ® ❑ DOD <br /> Dosing Chamber 600 600 Combination ® 0 0 ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumbees S' re MP/MPRS Number Business Phone Number <br /> Luke Schmitz 884121 715-468-2434 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> P.O.Box 160 Shell Lake WI 54871 <br /> VIII.County/Department Use Only <br /> ixApproved ❑ Disapproved Permit Fee Date Issued i,=`int Sign. .re <br /> ❑ Owner Given Reason for Denial $ 3�S 2/ w_i s, ,��/ <br /> IX.Conditions of Approval/Reasons for Disapproval 4' E © L5 0 V E <br /> Day.! ' .875 <br /> AU ` 1 021 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 U2 x I ch In size <br /> SBD-6398(R03/14) Burnett County' <br /> Land Se►virwc nennw........ <br />