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Industry Services Division County <br /> 4822 Madison Yards Way Burnett <br /> Madison,WI 53705 Sanitary Permit Number(tobe filled in by Co.) <br /> P$ P.O.Box 7302 ' �2 2_ L—1') <br /> Madison,WI 53707 csT-n2_ Lift 63 <br /> _ <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 24760 Anchor Inn Lane <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 /> Michael Anderson 014220502900 <br /> Property Owner's Mailing Address Property Location <br /> 19099 Fenway Ave N G°vt.L°t 1 <br /> City,State Zip Code Phone Number <br /> Forest Lake MN 55025 %, /, Section 05 <br /> II.Type of Building(check all that apply) Lot# T 38 N R 15 E or W <br /> Ell or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> [Public/Commercial-Describe Use <br /> City of <br /> Stale Owned-Describe Use CSM Number ❑Village of <br /> Town of Lafollette <br /> IIl.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' EINew System CRe lacement System rather Modification to ExistingSystem(explain) Additional Pretreatment Unit(explain) <br /> Y� P Y� Y� ( P ) ( P ) <br /> B. Holding Tank ❑ln-Ground at-Grade Mound 0 Individual Site Design ✓Other Type(explain) <br /> (conventional) eoMat <br /> C. 0 Renewal Before Revision Change of Plumber Transfer to New Owner <br /> 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(sf) System Elevation <br /> 450 1.6 281.25 367.5 89.25 <br /> Capacity in Total #of Manufacturer O <br /> Tank Information Gallons Gallons Units I.1 U d <br /> New Tanks Existing Tanks F o 2p 8 ,j et et <br /> c- U in , in ii t7 P. <br /> Septic or Holding Tank 1000 1000 1 Wieser I ✓ JI U U [R <br /> Dosing Chamber 600 0 1 L_1 l_I = CI <br /> V.Responsibility Statement-I,the undersigned,assume r onsi ity for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's matur MP/MPRS Number Business Phone Number <br /> Dan Burch 253808 715.416.1642 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> N5921 County Hwy K Spooner WI 54801 <br /> V ounty/Department Use Only <br /> Approved El Disapproved $ei f� Date Issued I ui g ent Signal <br /> El Owner Given Reason for Denial 5 p //`6i <br /> 00- <br /> Conditions of Approval/Reasons for Disapp oval <br /> ekkil.." <br /> I (4; EC� C� OdC� � <br /> T4u Iic� i s+ be a 1-- hit i/ei - an �1ood ✓� 915y $56 , <br /> AUU is 8 2O22 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 it2 x I l inchestn size <br /> Burnett County <br /> SBD-6398(R.02/22) Land Services Department <br />