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i � tART.Ng,�,r Department of Safety county <br /> BURNETT <br /> s� & Professional Services, <br /> Industry Services Division <br /> Sanitary Permit Number(to be filled in by Co.) <br /> 2.-Z� <br /> Wow 7 <br /> mn44`4 _ <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 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),Slats. 23595 OLD 35 <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> GRANT &HEIDI WILHELM 7-006-2-38-17-21-5 05-003-012000 <br /> Property Owner's Mailing Address Property Location <br /> 9116 TEWSBURY GATE Govt.Lot 1 <br /> City,State Zip Code Phone Number <br /> MAPLE GROVE, MN 55311 651-366-1647 '/<, '4, Secyytionn21�21 <br /> II.Type of Building(check all that apply) Lot# T 38 N R 17 `p, <br /> EX or 2 Family Dwelling-Number of Bedrooms 2 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 Ekown of DANIELS <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 X Replacement System Other Modification to Existing System(explain) El Additional Pretreatment Unit(explain) <br /> B' ❑ Holding Tank X in ground GEOMAT ❑ At-Grade Ar%..i Individual Site Design Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before ❑ Revision ❑Change of Plumber ❑Transfer to New Owner ist 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(st) System Elevation <br /> 300 2.0 150 162.50 95.64 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units U '$ y <br /> New Tanks Existing Tanks a 2 g pCd <br /> ti U iin ti w C7 is <br /> Septic or Holding Tank 840 840 1 X <br /> WIESER COMBO <br /> Dosing Chamber 500 500 <br /> V.Responsibility Statement-I,the undersigned,assume responsibi'ty for. start 'on of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature 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 Issued I ui gent Slanatdc <br /> ❑Owner Given Reason for Denial <br /> $L�aS I 0117/ <br /> Conditions of Approval/Reasons f rDisapproval <br /> Jr <br /> Y5efbq, 4 trt-�k <br /> 11 <br /> OCI 0 9 l", <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x t inches in siTurnett County <br /> Land Services Department <br /> SBD-6398(R.03/22) <br />