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Department of Safety County <br /> BURNETT <br /> 11 S & Professional Services, anitary Pent <br /> ut Number(to be filled in by Co.) <br /> p S T Industry Services Division 4,3 11�3 <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. 29079 E. YELLOW RIVER RD <br /> I.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> TRACY L. & RHONDA R. MANN 7-020-2-40-16-07-5 15-580-016000 <br /> Property Owner's Mailing Address Property Location NZ,,3q <br /> 6580 KIRKWOOD AVENUE Govt.Lot NA ��QQ <br /> City,State Zip Code Phone Number <br /> COTTAGE GROVE, MN 55016 651-775-0127 /<, %., Section 07 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 16 ]�X W <br /> 00 or 2 Family Dwelling—Number of Bedrooms 2 6 Subdivision Name <br /> ❑Public/Commercial—Describe Use Block# PARDUN'S RIVER PINES <br /> _ <br /> NA ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> NA Efown of OAKLAND <br /> 111.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 /> a icable.) <br /> New System Replacement System XOther Modification to Existing System(explain) U Additional Pretreatment Unit(explain) <br /> replace STEEL tank <br /> B. <br /> ❑ Holding Tank X in ground ❑ At-Grade l/G../ Individual Site Design Other Type(explain) <br /> (conventional) add filter <br /> C. ❑ Renewal Before ❑ Revision ElChange of Plumber ElTransfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration 91259/07-09-1987 <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required Dispersal Area Proposed System Elevation <br /> 300 0.7 (st)428.58 (sf)EXISTING: 432 96.40 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units <br /> New Tanks Existing Tanks u.° y d H n <br /> ` p 0 A .=d c0 <br /> aU W H rn wC7 a <br /> Septic or Holding Tank 1000 1000 1 WIESER X <br /> Dosing Chamber <br /> V.Responsibility Statement- 1,the undersigned,as me re ility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PI is S' n 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 /> �CApprovcd ❑Disapproved Permit Fcc � Date Issued Issui g gent Sig ure <br /> ❑Owner Given Reason for Denial 5375/ �/ <br /> Conditions of Approval/Reasons for Disapproval <br /> M eel- C,// 5a4C,c 5> <br /> I'veeG� �i��trr 5 iCS c4'rl�lIS D <br /> J U N 0 2 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 inch s in sr <br /> Burnett County <br /> SBD-6398(R.03/22) Land Services Department <br />