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�eMnrt�r County Industry Services Division BURNETT <br /> 1400 E Washington Ave <br /> s J. . Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 0 n <br /> Madison,WI 53707-7162 D <br /> S <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 tmit <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. 3680 S PENINSULA RD WEBSTER 54893 <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> STEVEN&KATHLEEN HALL 07-012-240-15-36-5 05-001-016000 <br /> Property Owner's Mailing Address Property Location <br /> 3243 BERWICK KNOLL <br /> Gov[.Lot I <br /> City,State Zip Code Phone Number /., b, Section 36 <br /> BROOKLYN PARK,MN 55443 (circle one) <br /> T40N; R15WEorW <br /> II.Type of Building(check all that apply) Lot# <br /> ® I or 2 Family Dwelling-Number of Bedrooms I Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> LOT I CSM V I P 103 ® Town of JACKSON <br /> Ill.Type of Permit: Check only one box on line A. Com tete line B if applicable) <br /> A. ❑New System ® Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B ❑ Permit Renewal ❑ Permit Revision ❑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 al]that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound?24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ® Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Trestment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 450 Rate(gpd4 N/A <br /> VI.Tank Info Capacity in <br /> GallonsTotal #of ° a <br /> Gallons Units Manufacturer <br /> New Tanks Existing Tanks it: U in rn cz 3 P. <br /> Septic or Holding Tank 2000 2000 1 WIESER CONCRETE ® ❑ ❑ 11 ❑ <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersignA aA e re ponsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prim) P et S' ature MP/MPRS Number Business Phone Number <br /> CORY JACKSON 824339 715-566-2786 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 9306 BLACK BROOK RD. WEBSTER, WI 54893 <br /> V IL Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial $ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ECEE E <br /> Attach to complete plans for the system and submit to the County only on paper not les+than 8 rn z I l inches' ire OCT 16 <br /> 0015 <br /> SBD-6398(R03/14) <br /> BURNET7COUNTY <br /> ZONING <br />