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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 /> _ P.O.Bn, x WI 537072 3 PN -2 2 -.04 / 6,W63,1 <br /> Madison,WI <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 Blue Dry r Lane <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. /,-3 <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Ellen Schreder 070362401713515600020000 <br /> Property Owner's Mailing Address Property Location <br /> 8545 Adair Circle N Govt.Lot <br /> City,State Zip Code Phone Number <br /> Brooklyn Park MN 55443 %. /. Section 13 <br /> II.Type of Building(check all that apply) Lot# T40 N R 17 E or W <br /> DI or 2 Family Dwelling-Number of Bedrooms 2 12 Subdivision Name <br /> Block# <br /> DPublic/Commercial-Describe Use <br /> City of <br /> ❑State Owned-Describe Use CSM Number Village of <br /> Princess Pine Shores Dow,of Union <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. <br /> New System EReplaeement System pother Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) <br /> ank Replacement <br /> B. Holding Tank ❑In-Ground ❑At-Grade ❑Mound ❑Individual Site Design jOther Type(explain) <br /> (conventional) <br /> C. IDRenewal Before ElRevision ❑Change of Plumber :Transfer 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(sl) Dispersal Area Proposed(sf) System Elevation <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units ao 4 0 A <br /> New Tanks Existing Tanks '- c y I? ' b <br /> o .. 2 <br /> n. U 'v rn I.L. C7 a. <br /> Septic or Holding Tank 750 750 1 Wieser I ✓ I I i I <br /> Dosing Chamber I I I I EJ - <br /> V.Responsibility Statement- I,the undersigned,assume res sibility r installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si re 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 /> VI.County/Department Use Only <br /> ie <br /> Approved 0 Disapproved { <br /> Permit� Fee Date Issued Is uin Age t Signatu <br /> 0 Owner Given Reason for Denial $ ✓75-- )0I 1-1'? - <br /> Conditions of Approval/Reasons for Disa proval <br /> tee all Se OCR jl s3 .7 <br /> N loin s cvsa 1 n oh Put IMP la 14 11,ECIEDV ElOCra32g12 <br /> Attach to complete plans for the system and submit to the County only on paper not less than It i12 x t 1 Mhe size <br /> Burnett County <br /> SBA-6398(R.02/22) Land Services Department <br />