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r,Rrvx County <br /> v ---- ' Department of Safety <br /> 1 c BURNETT <br /> '- 0� & Professional Services, <br /> Sanitary Permit Number(to be filled in by Co.) <br /> , `1 PS Industry Services Division 3L1 <br /> Sanitary Permit Application State T ansacti ' �um <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. 6018 LAKE 26 ROAD <br /> I.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> GARY J. & LORI L. VERHASSELT 07-032-2-41-15-19-3 04-000-014000 <br /> Property Owner's Mailing Address Property Location 4-a 4523 <br /> P.O. BOX 636 Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> OSCEOLA, WI 54020 SE /<, SW v., section 19 <br /> II.Type of Building(check all that apply) Lot# T 41 N R 15 w <br /> IX or 2 Family Dwelling—Number of Bedrooms 3 1 Subdivision Name <br /> Block# NA <br /> ❑Public/Commercial—Describe Use <br /> NA ❑City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of <br /> V3, P107 l Cownof 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. New System X Replacement System System(explain)❑Other Modification to Existing ❑Additional Pretreatment Unit(explain) <br /> B. 0 Holding Tank 0 At-Grade Mound X in ground Design ❑Other Type(explain) <br /> ❑Individual Site <br /> (conventional) <br /> C. ❑ Renewal Before 0 Revision ❑Change of Plumber 0 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) SystemElevation <br /> 450 0.7 642.86 652 .00 FT. <br /> Capacity in Total #of Manufacturer <br /> 11 <br /> Tank Information Gallons Gallons Units o <br /> New Tanks Existing Tanks d a d 2 1.1 , cl <br /> 0 <br /> a'". U in � in w C7 a <br /> Septic or Holding Tank 1050 1050 1 INFILTRATOR X <br /> Dosing Chamber <br /> V.Responsibility Statement-I,the undersigned, u e re sibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PI b 's Si re 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 0 Disapproved P$ rmit FeeLI�� �Dat/ /Issued [ u g gentSure <br /> 0 Owner Given Reason for Denial �` 3 <br /> Conditions of Approval/R son for Disapproval <br /> ()//kieel- ct 11 ACItS f 51-A.-te (,.44,./r644.A'h <br /> 9 ECER,E ----n <br /> MAY 0 4 2023 i U <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I inchesR n size <br /> Burnett County <br /> SBD-6398(R.03/22) Land Services Department <br />