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Department of Safety County <br /> Burnett <br /> &Professional Services, andiary Permit Number(to be filled in by Co.) <br /> Industry Services Division 20 <br /> Sanitary Permit Application State Transaction Number <br /> PWTS-082301857-C <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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. 24775 County Rd.H <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> P&L Landing Properties LLC 07-008-2-3 8-14-04-5-05-00 1-0 1 1 000 <br /> Property Owner's Mailing Address Property Location <br /> 1805 Kern Ave. Govt.Lot 1 <br /> City,State Zip Code Phone Number <br /> Rice Lake WI 54868 /4, h, Section 4 <br /> II.Type of Building(check all that apply) Lot# T 38 N R 14 E or W <br /> ❑1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> �./ <br /> ga_Eublic/Commercial-Describe Use Pole Shed Block# <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> own of <br /> Dewey <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 i <br /> applicable.) <br /> A >�New System ❑Replacement System ❑ Other Modification to Existing System(explain) El Additional Pretreatment Unit(explain) <br /> B. ❑ Holding Tank ❑ In-Ground At-Grade ❑Mound ❑ 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 <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) System Elevation <br /> 150 5 300 300 97.5 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units c .a <br /> U 2 <br /> New Tanks Existing Tanks o `_ J, <br /> G. U rA y cn W C7 0. <br /> Septic or Holding Tank 1000 1600 1 Wieser X <br /> Dosing Chamber 600 <br /> V.Responsibility Statement—I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature �� PRS Number Business Phone Number <br /> 1 <br /> Rick Brown \l 23 2 419-0739 <br /> Plumber's Address(Street,City,State,Zip <br /> Code) <br /> PO Box 637 Spooner WI 54801 <br /> VI.County/Department Use Only <br /> Permit Fee Date Issued Issuin gent nat re <br /> 'Approved ❑Disapproved <br /> ❑Owner Given Reason for Denial <br /> Conditions of Approval/Reasons for Disapproval <br /> 54t:�, - �✓�14t c1 a� c. I�L�I r�. <br /> v ntcrct'al Se of � ���`C f � . <br /> InD 001MVIE <br /> r. <br /> T fl A r nq I <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 i 11 i I ieasize <br /> Burnett County <br /> SBD-6398(R.03/22) Land Services Department <br />