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Department of Safety County BURNETT <br /> s-�; & Professional Services, <br /> Sanitary Permit Number(to be filled in by Co.) <br /> g Its � Industry Services Division <br /> W 23- L-21-1 <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 <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(I)(m),Stats. 5279 CRANBERRY LANE <br /> I.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> KAREN K. GOIKE TRUST 07-014-2-38-15-0A5-009-011000 <br /> Property Owner's Mailing Address Property Location � �1 a#-`7Y7z <br /> 2524 JEANNE LANE 9 <br /> Govt.Lot <br /> City,State Zip Code Phone Number <br /> EAU CLAIRE, WI 54703 /<. /<. Section OS <br /> II.Type of Building(check all that apply) Lot# T 38 N R 15 :� W <br /> IN or 2 Family Dwelling-Number of Bedrooms 2 NA Subdivision Name <br /> Block# NA <br /> ❑Public/Commercial-Describe Use <br /> NA ❑city of _ <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> NA Ek°—of l,AFOL.LETTE <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. ❑ New System EIReplacement System g y (explain) (explain) <br /> ❑ Other Modification to Existing SystemAdditional Pretreatment Unit <br /> B. X Holding Tank In ground ❑ At-Grade Mound ❑ Individual Site Desig <br /> n El Other Type(explain) <br /> (conventional) <br /> C. El Renewal Before ElRevision El Change of Plumber ist Previous Permit Number and Date Issued <br /> ❑ Transfer to New Owner <br /> Expiration NK <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow( d) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3p'� NA NA NA NA <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units <br /> New Tanks Existing Tanks U Y 9 <br /> w cn � <br /> cl <br /> Septic or Holding Tank 2000 2000 1 WIESER <br /> Dosing Chamber <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 Sig MP/ IPRS Number Business Phone Number <br /> natu <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 Pen-nit Feeeej Date Issued Issuin gent Signature <br /> \ ❑Owner Given Reason for Denial $ ✓� 31 I Is I 2,v <br /> Conditions of Approval/Reasons for Disapproval IyLionn <br /> — <br /> F-61 1vw au S-b,4 c,sid c°u t4v r-e tt i,-t�.s <br /> B4+nm 0- SJAR' 40 bL lid as ba-r JUN 2 2 2023 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 11 inches in net -o my <br /> Land Services Department <br /> SBD-6398(R.03/22) <br />