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C) . Department of Safety CountygURNETT <br /> & Professional Services Sanitary Permit Number(to be filled in by Co.) <br /> Industry Services Division <br /> e 57-023 - 147 k/5°9 q <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 Addres (iylibent than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary Too(TO <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. SKYLIGHT TER <br /> I.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> VOYAGER VILLAGE POA 07-012-2-40-15-22-5 15-705-053000 <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 763-406-9042 I•, '/., Section 22 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 15 X W <br /> [Xi or 2 Family Dwelling—Number of Bedrooms 2 43 Subdivision Name <br /> Block# SKYLIGH GLEN ADD <br /> ❑Public/Commercial—Describe Use <br /> NA ❑City of <br /> 0 State Owned—Describe Use CSM Number 0 Village of <br /> NA IN Town 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 /> X New System Replacement System Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) <br /> B. <br /> ❑ Holding Tank X in ground ❑ At-Grade MOW Individual Site Design Other Type(explain) <br /> (conventional) add filter <br /> C. ❑ Renewal Before ❑ Revision 0 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 Dispersal Area Proposed(sf) System Elevation <br /> 300 0.7 (sf)428.58 446 94.75 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units g V la 0 <br /> New Tanks Existing Tanks y a a 9 ',2CS <br /> P`. U r%3 h in w C'7 W <br /> Septic or Holding Tank 750 1 WIESER X <br /> 750 . <br /> Dosing Chamber <br /> V.Responsibility Statement-I,the undersigned,assume respo sibili for i Ration of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sign e 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 /> Permit Fee Date Issued Issuing gent Sign. re <br /> $ <br /> Approved ❑Disapproved 12�j r I <br /> 0 Owner Given Reason for Denial L`Q'�/ 1���O I oil <br /> Conditions of Approval/Reaso s for Disapproval <br /> ©I' I ee 4— all ,3cac k 5 U G,le eet,yeAtoitfs (t11 1'932 42-) <br /> IE C VIE <br /> J U N 2 9 2023 'Thn <br /> IV} <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size Burnett County <br /> Land Services Department <br /> SBD-6398(R.03/22) <br />