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r+ tsdc <br /> `* r Department of Safety County <br /> & Professional Services, ant Permit NBumberAD Ebe Tlied in byCo.)\:,,,;*,,, <br /> 1:.! Industry Services Division - .O <br /> Sanitary Permit Application State Transaction NumberaA,r j 19436 <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. ASPEN TERRACE <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> VOYAGER VILLAGE POA (ERIC LOOMIS CONSTRUCTION) 07-028-2-40-14-07-5 15-706-078000 <br /> Property Owner's Mailing Address Property Location <br /> 28851 KILKARE ROAD Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> DANBURY, WI 54830 952- 994 - 6924 IA, v., Section 07 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 14 2'6t W <br /> l l or 2 Family Dwelling-Number of Bedrooms 3 73 Subdivision Name <br /> Block# SPRING GREEN ADDN <br /> ❑Public/Commercial-Describe Use <br /> NA ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> NA EXIown 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 XOther Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) <br /> B. ❑ Holding Tank ❑ At-Grade / Individual Site Design Other Type(explain) <br /> CC in ground <br /> add filter <br /> C. U .Renewal Before ❑Revision ❑ Change of Plumber ❑Transfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration <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 96.00 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units a.) <br /> New Tanks Existing Tanks cog 11 v <br /> Septic or Holding Tank 1000 <br /> 1000 1 WIESER X <br /> Dosing Chamber <br /> V.Responsibility Statement- I,the undersigned,assume respo bili or in nation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sign 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 Date Issued12 Issui g ent S' a e <br /> 00 <br /> 0 Owner Given Reason for Denial $y -5 (j� 4*/✓ C/Ll r <br /> Conditions of Approval/Reaso s for Disapproval <br /> niee,-4- ali 58-b 4 ez, 56,..4e (74.,,Nc <br /> IIEC MED <br /> JUN 2 8 2023 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/2 x 11 itches in size Burnett County <br /> Land Services De.artment <br /> SBD-6398(R.03/22) <br />