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Department of Safety County <br /> \; & Professional Services, BURNETT <br /> $ Sanitary Permit Number(to be filled in by Co.) <br /> pe Industry Services Division S -1bI- <br /> �5�f85� <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),Stars. 27649 <br /> I.Application Information—Please Print All Information JAMIE LANE <br /> Property Owner's Name Parcel# <br /> BRYAN & BONNIE TRANDAHL 7-012-2-40-15-26-5 05-004-028000 <br /> Property Owner's Mailing Address Property Location--rs /)� 4�& 029000 <br /> 9441 CLINTON AVENUE S Govt.Lot 4 <br /> City,State Zip Code Phone Number <br /> BLOOMINGTON, MN 55420 612-248-9361 i<, i<, Section 26 <br /> IL Type of Building(check all that apply) Lot# T 40 N R 15 J'b W <br /> IN or 2 Family Dwelling—Number of Bedrooms 3 9& 10 Subdivision Name <br /> Block# NA <br /> ❑Public/Commercial—Describe Use <br /> NA ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> #1959;V 10,P331 Flown of JACKSON <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 /> XNew System Replacement System Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain) <br /> B. <br /> ❑ Holding Tank 7{ in ground ❑ At-Grade !A'...../ Individual Site Design Other Type(explain) <br /> (conventional) add filter <br /> C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner 1st 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(st) System Elevation <br /> 450 0.7 642.86 652 95.00&94.00 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units V U ) y <br /> New Tanks Existing Tanks a �' ro <br /> 0 2 <br /> a U in to <br /> Septic or Holding Tank 1000 1000 1 X <br /> WIESER <br /> Dosing Chamber <br /> V.Responsibility Statement- I,the undersigned,assume respons' ility r instyllation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signa P/MPRS Number Business Phone Number <br /> M <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 n� gg Agent ign re <br /> ❑Owner Given Reason for Denial t`ll d^CS S &s <br /> Conditions of Approval/Reason for Disapproval <br /> �I ee c•ll s .e fG E s �e rti. ��-s / <br /> LCAs 4 to � cap►6 n�, v 4. Cer�i���¢ ,✓✓ rk"' l5 V <br /> r?' 1�1ALTWC or S;toto'*P dvt!sIl �>t� t,✓�. D <br /> 5e�6as o/ CroS5�3 4 P'OP` li 5. <br /> v Ai;6 L 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 1 inches to st'Surnett County <br /> Land Services Department <br /> SBD-6398(R.03/22) <br />