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��*'""T4:*7 Department of Safety County <br /> & Professional Services, BURNETT <br /> : *,, Sanitary Permit Number(to be filled in by Co.) <br /> Industry Services Division g %J a3_ ,�3 a 65b937 <br /> ��11 qq rv�� <br /> ttri ap 1_ O { --G3 <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. (SAME) <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> PATRICK L. & SUSAN L. MCFADDEN 07-020-2-40-16-12-5 05-006-01911 <br /> Property Owner's Mailing Address Property Location 4 . 36-5 5 7 <br /> 28132 S. JOHNSON LAKE ROAD Govt.Lot 6 <br /> City,State Zip Code Phone Number <br /> WEBSTER, WI 54893 v., 'A, Section 23 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 16 .*b4W <br /> 00 or 2 Family Dwelling-Number of Bedrooms_ 3 1 Subdivision Name <br /> Block# NA <br /> o Public/Commercial-Describe Use <br /> NA ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> #4923 mown of OAKLAND <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 aReplacement System ❑Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) <br /> B. t ❑Other Type(explain)❑ Holding Tank in ground ❑ At-Grade ound ❑Individual Site Design yp ( p ) <br /> (conventional) <br /> C. U .Renewal Before ❑Revision ❑ Change of Plumber ❑Transfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration NK <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 2.0 225 292.50 104.33 FT. <br /> Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o v <br /> Tank Information a ,. <br /> New Tanks Existing Tanks - a v " 0 y 2 1 <br /> 0 <br /> P. U 'vn . rn u. C7 C+. <br /> Septic or Holding Tank 1000 1000 1 WIESER (COMBO) X <br /> Dosing Chamber 650 ,50 <br /> V.Responsibility Statement- I,the undersigned,ass e resp n'bility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu e Si: e MP/MPRS Number Business Phone Number <br /> CORY J. JACKSON Al 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 Feed Date Issued Iss in A ent Si ttak�e <br /> 0 Owner Given Reason for Denial <br /> 145✓ ‘, 15/a3 ' ,..&, o_ <br /> Conditions of Approval/Reas ns for Disapproval <br /> olect al/ 54 s -r 5-Wk c -1(9 '5 <br /> lECE [IVE o <br /> MAY 12 2023 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 a 11 itch m size <br /> Burnett County <br /> SBD-6398(R.03/22) Land Services Department <br />