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t"`T'4_. Department of Safety County BURNETT <br /> & Professional Services,Industry Services Division Sanitary Permit Number(to be filled in by Co.) <br /> kJ r -?3 _ ! $( (o64T�-72 <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 PWTS-082336903-C <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. 7027 AUSTIN LAKE ROAD <br /> I.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> BRUCE A. & CHRISTINE M. GIBBS 07-018-2-39-16-09-1 01-000-011000 <br /> Property Owner's Mailing Address Property Location <br /> P.O. BOX 46 Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> Section 09 <br /> WEBSTER, WI 54893 715-866-8364 NE i, NE i, <br /> II.Type of Building(check all that apply) Lot# T 39 N R 16 `BX W <br /> CX)or 2 Family Dwelling—Number of Bedrooms 3 NA Subdivision Name <br /> Block# NA <br /> ❑Public/Commercial—Describe Use <br /> NA ❑city of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> NA [kown of MEENON <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 LIReplacement System y (explain)❑Other Modification to ExistingSystemAdditional Pretreatment Unit(explain) <br /> B' ❑ Holding Tank in ground ❑ At-Grade Exmound ❑ Individual Site Design ❑Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before ❑ Revision ❑Change of Plumber ❑ Transfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration 258441 <br /> IV.DispersaLrrreatment 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 2.0 225 292.50 100.40 FT. <br /> Capacity in Total #of Manufacturer <br /> c <br /> Tank Information Gallons Gallons Units g <br /> New Tanks Existing Tanks <br /> a U in ti y w C7 A., <br /> Septic or Holding Tank 1000 1000 1 WIESER (COMBO) X <br /> Dosing Chamber 600 600 <br /> V.Responsibility Statement-1,the undersigned,assume responsi ility f ins lion of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signatur 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 ssued gtenl <br /> Si to <br /> Approved ❑Disapproved $r-� I� n /�4�� <br /> ❑Owner Given Reason for Denial 3 ./{ `� / <br /> Conditions of Approval/Reasons fo Disapproval <br /> �►'1Ce.� all -sc-fba S f Jr,7 "Ao+'� LIL 7 <br /> %EP 1 1 2023 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 nches isizeBurnett County <br /> Land Services Department <br /> SBD-6398(R.03/22) <br />