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Department of Safety County <br /> ��� • ' , BURNETT <br /> & Professional Services, <br /> S itary Permit Number(to be filled in by Co.) <br /> Industry Services Division �-a3 — 198' <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 QX 1b c 5 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. D ERPATH ROAD <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> SM WOLF HOLDINGS LLC DBA TIMBERLAND COTTAGES 7-012-2-40-15-10-5 15-128-212000 <br /> Property Owner's Mailing Address Property Location <br /> 19200 COUNTY RD 40 Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> BELLE PLAINE MN 56011 952- 994 - 6924 'i v4, Section 10 yy <br /> II.Type of Building(check all that apply) Lot# T 40 N R 15 ]L W <br /> 00 or 2 Family Dwelling-Number of Bedrooms 3 203 Subdivision Name <br /> Block# DEERPATH ADDN <br /> ❑Public/Commercial-Describe Use <br /> NA ❑city of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> NA [gown 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. XNew System Replacement System %Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain) <br /> B• ❑ Holding Tank X in ground ❑ At-Grade Individual Site Design Other Type(explain) <br /> (conventional) add filter <br /> C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner ist Previous Permit Number and Date Issued <br /> Expiration IL <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 /> 450 0.5 900 918 96.75 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units U y <br /> New Tanks Existing Tanks = c <br /> Septic or Holding Tank 1000 1000 1 WIESER X <br /> Dosing Chamber <br /> V.Responsibility Statement-I,the undersigned,assume responsibility or insliallation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signa MP MP ,S 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 $e;mtFee Date Ied,23 Is ui g ant a e <br /> ❑Owner Given Reason for Denial `UI/J5 R// (/ <br /> Conditions of Approval/Reas s for isapproval <br /> meek- alb se+backs -F 54 <br /> k ,',-0 D -- c,� <br /> BurniM Coax vy <br /> Land Serviom <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size <br /> SBD-6398(R.03/22) <br />