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oa� tART MrA�i Department of Safety county BURNETT <br /> Y . & Professional Services, <br /> Sanitary Permit Number(to be filled in by Co.) <br /> Industry Services Division 3_1 99 659M <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 (� �j <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Slats. �a� D DE RP�ATH ROAD <br /> I.Application Information-Please Print All Information 1433Yi <br /> Property Owner's Name Parcel# <br /> SM WOLF HOLDINGS LLC DBA TIMBERLAND COTTAGES 7-012-2-40-15-10-5 15-128-214000 <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 '/• '/4, Section 10 yy <br /> II.Type of Building(check all that apply) Lot# T 40 N R 15 `L'4w <br /> EYJ or 2 Family Dwelling—Number of Bedrooms 3 205 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. <br /> XNew System Replacement System Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) <br /> B' ❑ Holding Tank X in ground ❑ At-Grade lG.✓ Individual Site Design Other Type(explain) <br /> (conventional) I add filter <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 /> 450 0.5 900 918 95.00 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units t? d y <br /> New Tanks Existing Tanks c « M <br /> n. U in ti rn is. C7 a. <br /> Septic or Holding Tank 1000 1000 1 WIESER X <br /> Dosing Chamber <br /> V.Responsibility Statement-I,the undersigned,assume respon 'bilityfpr ins ation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signa 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 /> Approved ❑Disapproved Fe it Fee Date <br /> e Issued I s n Age Si ture <br /> ❑Owner Given Reason for Denial L1J 90193 <br /> 19 <br /> Condef�Appro;Zasons,for Disapproval n, , , <br /> d CSC =��C� <br /> S E P 14 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 in sburnett County <br /> Land Services Department <br /> SBD-6398(R.03/22) <br />