Laserfiche WebLink
Industry Services Division County <br /> f% 4822 Madison Yards Way Burnett <br /> Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> 43i <br /> ,ry P.O.Box 7302 c/ptb <br /> Madison,WI 53707 lD5 U J <br /> �Y�t�94tiwl,r� <br /> Sanitary Permit Application State Transaction Num e <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <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 6441 Lilly Ln <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Stats. <br /> I.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> Steven John Fahrner Rev Trust 020906001400-r p:i (Z <br /> Property Owner's Mailing Address Property Location <br /> 5230 girard ave s Govt.Lot <br /> City,State A419 <br /> Code Phone Number <br /> Minneapolis MN %. 14, Section 02 <br /> II.Type of Building(check all that;apply) Lot# T40 N R 16 E o <br /> 1-3 l or 2 Family Dwelling—Number of Bedrooms 4 Subdivision Name <br /> Block# <br /> ablic/Commercial—Describe Use <br /> []City of <br /> ❑State Owned—Describe Use CSM Number illagc of <br /> 2119 QTown of Oakland <br /> Ill.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on A. Check one box on fine B.Complete line C i <br /> a livable. <br /> A. [:]New System a lacement System her Modification to Existing System(explain) Additional Pretreatment Unit(explain) <br /> ❑1`I Y' �P Y ❑� g Y ( P ) ❑ ( P ) <br /> B. ❑Flolding Tank nln-Ground [:]At-Grade ❑Mound Individual Site Design Other Type(explain) <br /> RLI(conventional) <br /> C. ❑Renewal Before ❑Revision hange of Plumber ❑Transfer to New Owner rst Previous Permit Number and Date Issued <br /> Expiration 133 v l <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Desilm Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) I System Elevation <br /> y 4 6- a 19-7 95 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units U U $ <br /> New Tanks Existing Tanks c B r a <br /> U in ; Sn i C7 P <br /> Septic or Holding Tank J 0 0 u ! a Of3 ( l `a 5 C r <br /> Dosing Chamber ❑ ❑ <br /> V.Responsibility`Statement-1,the undersigned,assume responsi !of stallation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Dan Burch 253808 715.416.1642 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> N5921 County Hwy K Spooner WI 54801 <br /> V1.Coarrtyll?epartmt%t Use Ord$ <br /> 'Approved 0 Disapproved Permit Feed Date Issued/ Issu g Agent Si a re <br /> ❑Owner Given Reason for Denial Tq aS <br /> Conditions of Ap roval/Reasons for Disapproval <br /> IM c�e�- q d� sal-b�is f s� .;�`n"/C� �c� <br /> o� ?1,C <br /> $ �k gy <br /> 4� Q � <br /> ECEME �nJ <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I ' c a n s''��Uu t` 2 4 2023 <br /> 10 <br /> SBD-6398(R.02/22) <br /> Burnett County <br /> Land Services Departmern <br />