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Department of Safety County <br /> • <br /> o &Professional Services, BLJRNETT <br /> II Sanitary Permit Number o be filled in by Co.) <br /> PS Industry Services Division 5AN-22_ <br /> C'0'1 22- .2/4 �' �`�J <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 mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. 30684 JOHNSON LAKE DRIVE <br /> I.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> CORY&JESSICA JACKSON 07-032-2-41-15-24-5 05-002-012000 <br /> Property Owner's Mailing Address Property Location <br /> 9306 BLACK BROOK ROAD Govt.Lot 2 <br /> City,State Zip Code Phone Number <br /> WEBSTER, WI 54893 715 -791 -4768 v, v., Section 24 <br /> II.Type of Building(check all that apply) Lot# T 41 N R 15 IX <br /> 00 or 2 Family Dwelling—Number of Bedrooms <br /> 3 3 Subdivision Name <br /> Block# NA <br /> o Public/Commercial—Describe Use <br /> NA ❑City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of <br /> V18, P87 Ii'ownof SWISS <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 XOther Modification to Existing System ❑Additional Pretreatment Unit(explain) <br /> (explain) UPGRADING TO A 3 BEDROOM <br /> B' ❑Holding Tank I 4 Ground 0 At-GradeType( p ) <br /> n- ❑Mound 0 Individual Site Design ❑Other ex lain <br /> (conventional) <br /> C. 0 Renewal Before 0 Revision 0 Change of Plumber 0 Transfer to NewOwner List Previous Permit Number and Date Issued <br /> Expiration 588629 <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 0.7 642.86 652 95.00 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units ..o o '0„ <br /> New Tanks Existing Tanks i c Ity , `� <br /> At V iz , rn Gi C7 R. <br /> Septic or Holding Tank 1000 1600 2600 1 WIESER X <br /> Dosing Chamber 650 650 1 WIESER X <br /> V.Responsibility Statement-I,the undersigned,a me resale, ity for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu. .,•is Si a< ri- MP/MPRS Number Business Phone Number <br /> CORY J.JACKSON 824339 715-866-8944 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 24884 S.T.H. 35, SIREN, WI 54872 <br /> VI.County/Department Use Only <br /> ,Approved ❑Disapproved Permit Fee p Date Issued • g gent ignature <br /> ❑Owner Given Reason for Denial $ l 2 I ( 1 0 l a� <br /> Conditions of ApprovaUReaso for D' proval (� V �— <br /> (Yl ee4- 61( Sc� pa 5-f V frycAbfr y 'iaS <br /> NOV 3 2022 <br /> • <br /> Burnett County <br /> Lard Services DeparYmsnt <br /> Attach to complete plans for the system and submit to the County only on paper not less than S la a II inches in size <br /> SBD-6398(R.03/22) <br />