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� �Rrur Department of Safety County BURNETT <br /> & Professional Services, <br /> anitary Permit Number(to be filled in by Co.) <br /> Industry Services Division lktJ -W_Z/ may, <br /> *F'-SS'Ni � J <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. ��� <br /> I.Application Information—Please Print All Information DEERPATH ROAD <br /> Property Owner's Name Parcel# '-rb1X_`D %5-1 <br /> TIMBERLAND COTTAGES 7-012-2-40-15-10-5 15-128-174000 <br /> Property Owner's Mailing Address Property Location <br /> 19200 CO.RD.40 Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> BELLLE PLAIN, MN 56011 NW��,, NE v., section 10 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 15 :W W <br /> M or 2 Family Dwelling—Number of Bedrooms 3 165 Subdivision Name <br /> Block# VOYAGER VILLAGE <br /> ❑Public/Commercial—Describe Use <br /> NA ❑city of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> NA EXown 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. IY P Y g Y (explain) (explain) <br /> X New System Replacement System Other Modification to Existing System ❑ Additional Pretreatment Unit <br /> B' ❑ Holding Tank X in ground ❑At-Grade ffl"Oe Individual Site Design Other Type(explain) <br /> (conventional) <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 0.7 642.86 652 93.50 FT. <br /> Capacity in Total #of Manufacturer :: <br /> Tank Information Gallons Gallons Units g t? '$ y 2 <br /> New Tanks Existing Tanks c p ea <br /> a U iTi y co 4. 0 Gi <br /> Septic or Holding Tank <br /> 1000 1000 WIESER X <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 Signatur, MP/MPRS Number Business Phone Number <br /> CORY J. JACKSONOZ 824339 715-866-8944 <br /> YA <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 Fe e Date Issued Issuin gent Signature <br /> ❑Owner Given Reason for Denial $V5 qlqlga� <br /> Conditions of Approval/Reasons for Disapproval <br /> 'ellow au. Ca/-y od s -k <br /> &Pc.1 mark 4t b C(aii-�ed a4 4tG t APR 1 J 2024 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x ll nches in size urnett County <br /> Land Services Department <br /> SBD-6398(R.03/22) <br />