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Department of Safety county <br /> BURNETT <br /> 0 =; & Professional Services, <br /> S Sanitary Permit Number(to be filled in by Co.) <br /> pS Industry Services Division sA� G-4/3 <br /> -39 �5� 9 <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 a <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. <br /> I:.Application Information-Please Print All Information 4392 HONEY TREE ROAD <br /> Property Owner's Name Parcel# <br /> SCOTTFATON TAX ID: A:n <br /> Property Owner's Mailing Address Property Location <br /> 656 CASTLE RIDGE ROAD Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> WATERTOWN, MN 55388 612-501-6057 '4, i4, Section 10 <br /> 11.Type of Building(check all that apply) Lot# T 40 N R 15 <br /> EYJ or 2 Family Dwelling-Number of Bedrooms 3 219 & 220 Subdivision Name <br /> Block# DEERPATH ADDN TO VOYAGER VIL <br /> ❑Public/Commercial-Describe Use <br /> NA ❑city of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> NA Ekown 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 /> X New System Replacement System Other Modification to Existing System(explain) El Additional Pretreatment Unit(explain) <br /> B. <br /> Holding Tank X in ground ❑ At-Grade 9�.«/ Individual Site Design Other Type(explain) <br /> (conventional) <br /> C. Rene al Before ❑ Revision Change of Plumber Transfer to New Owner <br /> List 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 System EnO <br /> . n <br /> 450 0.7 642.86 652 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units <br /> New Tanks Existing Tanks o B a A <br /> a U C/) 7 <br /> Septic or Holding Tank 1000 1000 1 WIESER X <br /> Dosing Chamber <br /> V.Responsibility Statement-I,the undersigned,assume responsibilityAfor ins Nation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signa a 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 Perrmmit Fee OD Date Issue Issuin gent Signature <br /> ❑Owner Given Reason for Denial $ / `� f`-`��� <br /> Conditions of Approval/Reasons for Disapproval <br /> MW CW 5' aj-S � � <br /> mush have 3f+ � S4S-4W � D'` i m►-�i�y - F.� I V IE <br /> Su lS �+p ' 4-it d ►'+'lt' 4 1 nSFCLf/t'n D _. <br /> FDl1 OW ail Coup+I tnd S_�rt* refer►rt~+s MAR 18 2024 <br /> Lo �9 � Attach to complete plans for the system and submit to the County only on paper not less than S 1/2 x 11 i ches in s'ze - 0 <br /> o -� � COmlo�r� d �� A C2r-h�e c� �f N�u� Burnett County <br /> �`( Land Services Department <br /> SBD-6398(R.03/22) <br />