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Department of Safety County <br /> D & Professional Services, BURNETT <br /> pSanitary Permit Number(to be filled in by Co.) <br /> P$ �, Industry Services Division -22— 22 <br /> � �,.. csr 2,2 —179 <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 NA <br /> is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than m ailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary 1 <br /> 8457 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Slats. �� /� ,,��JJ j DEr KYATH PASS <br /> I.Application Information-Please Print All Information vV <br /> Property Owner's Name Parcel# <br /> MDWST LLC (Kevin Breister) 07-012-2-40-15-10-5 15-128-204000 <br /> Property Owner's Mailing Address Property Location <br /> 112 FAIR MEADOWS PKWY Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> FOREST CITY, IA 50436 515 - 777= 5325 / /<, Section 10 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 15 <br /> EN or 2 Family Dwelling-Number of Bedrooms 2 195 Subdivision Name <br /> Block# DEERPATH ADDN. <br /> o Public/Commercial-Describe Use <br /> NA ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> NA Eitown of JACKSON <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 Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain) <br /> B. <br /> ❑ Holding Tank [ In-Ground ❑ At-Grade ❑ Mound Individual Site Design Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before ElRevision ElChange of Plumber ❑Transfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration <br /> IV.DispersaUTreatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Ratc(gpd/sf) Dispersal Arca Required(sf) Dispersal Arca Proposed(at) System Elevation <br /> 300 0.5 600 612 99.55; 98.55 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons UnitsE. c 14 <br /> New Tanks Existing Tanks ,,,,,'"A "6 ti y <br /> E c B ' ao. U n w rn w C <br /> Septic or Holding Tank 750 750 1 WIESER X <br /> Dosing Chamber <br /> V.Responsibility Statement- I,the undersigned,as me respo ' y for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu .-/s SignaF <br /> MP/MPRS Number Business Phone Number <br /> CORY J. JACKSON /� 824339 715-866-8944 <br /> Plumber's Address(Street,City,State,Zip Code) 111 <br /> 24884 S.T.H. 35, SIREN, WI 54872 <br /> VI.County/Department Use Only <br /> Xf <br /> Approved 0 Disapproved Permit <br /> Fee G ID Date Issued WISignatur <br /> 0 Owner Given Reason for Denial $ <br /> 14Q(5 ?I?7/;? <br /> Conditions of Approval/Reasons for Di approv 1 <br /> file-e4-- all 5e+ 5 <br /> • <br /> (.1,4N 4051, 14.2C <br /> E © E [IV ll <br /> '7a2s 2322 <br /> - <br /> .�/Y <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 elhe size <br /> Burnett County <br /> SBD-6398(R.03/22) Land Services Department <br />