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Industry Services Division County <br /> =` 4822 Madison Yards Way Burnett <br /> Madison,WI 53705 Sanitary Permit Number(to be filled in by <br /> p! P.O.Box 7302 0.) 2-2.n <br /> W_2s1 Z <br /> Madison,WI 5302 1'S %6J'T <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 is <br /> required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to the Project Address(if different than mailing <br /> Department of Safety and Professional Services.Personal information you provide may be used for secondary address) <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. Berg lake trail <br /> I.Application Information-Please Print All Information T 17 ( <br /> Property Owner's Name Parcel# <br /> ROBERT BARNES 07-032-2-41-15-19-5 15-443-024000 <br /> Property Owner's Mailing Address Property Location <br /> 3250 FILLMORE ST NE <br /> Govt.Lot <br /> City,State Zip Code Phone Number <br /> MINNEAPOLIS MN 55418 Section 19 <br /> II.Type of Building(check all that apply) Lot# T 41 N R 15 W <br /> ❑x 1 or 2 Family Dwelling-Number of Bedrooms 3 14 Subdivision Name <br /> Lost Acres <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> x❑Town of 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 <br /> if applicable.) <br /> A. P5Gew Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain) <br /> System <br /> B. ❑ Holding n-Ground ❑ At-Grade Mound ❑ Individual ❑ Other Type(explain) <br /> Tank (conventional) Site Design <br /> C. ❑ Renewal ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner List Previous Permit Number and Date Issued <br /> Before <br /> Ex iration <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area System Elevation <br /> 450 .7 2 Proposed(sf) 86/85 <br /> 1652 <br /> Capacity Total #of Manufacture <br /> Tank Information in Gallons Units <br /> Gallons <br /> New Existing Tanks <br /> Tanks a. in t V) J. C7 c% <br /> Septic or Holding Tank x 1000 1 Wieser <br /> Dosing Chamber <br /> V.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumbe ' ature MP/MPRS Business Phone Number <br /> Luke Schmitz Number 715-520-2434 <br /> 884121 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Po Box 160 Shell Lake WI 54871 <br /> VI.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent ' nature <br /> ❑Owner Given Reason $ �-S I494a3 <br /> for Denial <br /> a SEP 2 8 2023 <br /> Burnett County <br /> Land Services Department <br /> —!5(a(a(Q <br /> 0 <br /> �q a�° - <br />