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*A�r Department of Safety county <br /> xu p -, & Professional Services, BURNETT <br /> Sanitary Permit Number(to be filled in by Co.) <br /> PS Industry Services Division flPJ �_(��, <br /> 4�Sglri�\4 <br /> 4058 5701 <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),Stats. <br /> I.Application Information—Please Print All Information 5462 BUSHEY ROAD <br /> Property Owner's Name Parcel# <br /> MATTHEW E. & MAUREEN M. THOMPSON TAX ID: 34199 <br /> Property Owner's Mailing Address Property Location <br /> 9578 COTTONTAIL DRIVE Govt.Lot 1 <br /> City,State Zip Code Phone Number <br /> ST. BONIFACIUS, MN 55375 612-802-7642 1A, 1A, Section 19 <br /> 11.Type of Building(check all that apply) Lot# T 40 N R 15 <br /> IN or 2 Family Dwelling-Number of Bedrooms 2 NA Subdivision Name <br /> Block# NA <br /> ❑Public/Commercial-Describe Use <br /> NA El 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. ❑ Additional Pretreatment Unit(explain) <br /> X New System Replacement System Other Modification to Existing System(explain) ( p ) <br /> B. Holding Tank X in ground ❑ At-Grade '..! Individual Site Design Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before g List Previous Permit Number and Date Issued <br /> ❑ Revision Change of Plumber Transfer to New Owner <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 Ele ation <br /> 300 0.7 428.58 450 q(p 00 FT. <br /> Capacity in Total #of Manufacturer Y <br /> Tank Information Gallons Gallons Units o <br /> New Tanks Existing Tanks _ <br /> a U iin rn % C7 S <br /> Septic or Holding Tank 750 750 1 WIESER X <br /> Dosing Chamber <br /> V.Responsibility Statement-I,the undersigned,assume respyf sibil' for' fellatio.of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si e 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 $ ��v Permit Fee Da Issu d Issuing Agent Signature <br /> ElOwner Given Reason for Denial <br /> Conditions of Approval/Reasons for Disapproval <br /> 55as <br /> Fol[aw i �ouh�-r �to� S-fu-k re�uir�r 'r�S �, a�r,� LF r-r= <br /> -L <br /> MuS� 3 �� - sus-�-m PD <br /> n'I MIAR 18 20724 <br /> Attach to complete plans for the system and submit to the County only on paper not less than S 1/2 x 11 i c es in size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R.03/22) <br />