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\,: K z 4t,, County <br /> �,� Department of Safety <br /> , � & Professional Services, BURNETT <br /> 1 .Ps j Industry Services Division Sanitary Permit Number(to be filled in by Co.) <br /> t: ,:!a-/ <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(1)(m),Stats. 24293 NELSON ROAD <br /> I.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# --r" i D : 95 i 3 <br /> Ea\.,...T as-a S 01/4_0.S 07-014-2-38-15-07-1 03-000-011000 <br /> Property Owner's Mailing Address Property Location <br /> ag 3 6 c=.Y 'P...•A Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> W2b .\' W::\-, 715-279-2046 <br /> '/<, '/, Section 07 <br /> II.Type of Building(check all that apply) Lot# T 38 N R 15 <br /> 11)0 or 2 Family Dwelling—Number of Bedrooms <br /> 2 NA Subdivision Name <br /> Block# NA <br /> ❑Public/Commercial—Describe Use <br /> NA 0 City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of <br /> NA Mown of LAFOLLETTE <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. Other Modification to Existing System(explain) <br /> x New System Replacement System ❑ Additional Pretreatment Unit(explain) <br /> B. <br /> ❑ Holding Tank X in ground ❑ At-Grade 9X.../ Individual Site Design Other Type(explain) <br /> (conventional) <br /> C• U .Renewal Before ❑ Revision ❑Change of Plumber ❑ Transfer to New Owner <br /> List:Previous Permit Number and Date Issued <br /> Expiration I N\/ <br /> IV.DispersaUTreatment Area and Tank Information: v <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 0.7 428.58 452 95.00 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units a ) o 'g 0 <br /> New Tanks Existing Tanks d o d 1 ^ t <br /> aU inm en w0 a. <br /> Septic or Holding Tank <br /> 750 750 1 X <br /> WIESER <br /> Dosing Chamber <br /> V.Responsibility Statement- I,the undersigned,assume r spon ' ility f r installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signa 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 /> CI Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> $ <br /> ❑Owner Given Reason for Denial <br /> Conditions of Approval/Reasons for Disapproval ji'YZS #S5t1 <br /> SEE REVISION1, -ECE1NE <br /> li NOV 3 0 2023 <br /> Burnett County <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/1 x 1 inchcIANizervices Liepartment <br /> SBD-6398(R.03/22) <br />