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� "" kr Department of Safety c°°nty BURNETT <br /> & Professional Services, <br /> Sanitary Permit Number(to be filled in by Co.) <br /> Industry Services Division <br /> Sanitary Permit Application State Transaction Number <br /> hi 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),Stars. 3828 RAINBOW CIRCLE <br /> I.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# -Ca-y- %b <br /> JUDITH P. BALDERSON TRUST (KIM SOLLIE) 7-012-2-40-15-11-5 15-650-037000 <br /> Property Owner's Mailing Address Property Location <br /> 7884 TAYLOR STREET NE Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> SPRING LAKE PARK, MN 55432 715- 222-5808 '/<. v4, Section 11 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 15 : W <br /> IN or 2 Family Dwelling-Number of Bedrooms 3 28 Subdivision Name <br /> Block# RAINBOW POND ADDITION <br /> ❑Public/Commercial-Describe Use <br /> NA ❑city of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> NA Evown 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 /> New System X Replacement System XOther Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain) <br /> REPLACE TANK ONLY <br /> B. ❑ Holding Tank X m ground ❑ At-Grade Individual Site Design Other Type(explain) <br /> (conventional) add filter <br /> C. ❑ Renewal Before ❑ Revision ❑Change of Plumber ElTransfer to New Owner ist Previous Permit Number and Date Issued <br /> IL <br /> Expiration 09257/06-21-1977 JO<!�o <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sl) Dispersal Area Proposed(sf) System Elevation <br /> 450 0.7 642.86 652 T. 97. 0 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> c 2s <br /> Septic or Holding Tank �ff 32T) 750 1290 2 _.-~�_�++ � & X x <br /> T.Tnn�lroe�c� �) <br /> Dosing Chamber -1�50 <br /> V.Responsibility Statement-I,the undersigned,assume responsibili f�tallllatnion of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sign re 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 It�s""sueddhh Issuing Agent Signatur <br /> ❑.Owner Given Reason for Denial $���� <br /> Conditions of Approval/Reasons for Disapproval <br /> Nft4 W ;t4a4s D k�� <br /> �la-v U CW* 4261 S*-k ��� APR 10 2G24 I <br /> Burnett County <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 to <br /> + 1 <br /> SBD-6398(R.03/22) <br />