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�7pART" r� Department of Safety county <br /> BURNETT <br /> & Professional Services, <br /> Sanitary Permit Number(to be filled in by Co.) <br /> r Industry Services Division ��(023— <br /> 4 <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. 3060 ASPEN TERRACE <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> DEAN B. HILGERS 7-028-2-40-14-07-5 15-706-088000 <br /> Property Owner's Mailing Address Property Location <br /> 6980 LAKETOWN PKWY Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> WACONIA, MN 55387 /4, /<, Section 07 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 14 : bN W <br /> CYJ or 2 Family Dwelling-Number of Bedrooms 2 84 Subdivision Name <br /> Block# SPRING GREEN ADDN <br /> ❑Public/Commercial-Describe Use _ <br /> NA ❑City of _ <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> NA Mown of SCOTT <br /> I11.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) El Additional Pretreatment Unit(explain) <br /> B. ❑ Holding Tank X in ground GEOMAT ❑ At-Grade ../ 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 /> 300 2.0 150 162.50 9P.177FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units c '8 0 <br /> New Tanks Existing Tanks y <br /> a U in y ti w 0 a. <br /> Septic or Holding Tank 840 840 1 WIESER (COMBO) X <br /> Dosing Chamber 500 500 <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 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 Permit Fee� Date Issued <br /> 'j 2 Issui g A ent Si re <br /> ❑Owner Given Reason for Denial $''1�J/ 'I p J <br /> Conditions of Approval/R asons for Disapproval <br /> CEW <br /> JUL 10 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 nche'00d'Services Department <br /> 1 SBD-6398(R.03/22) <br />