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Department of Safety i Burnett <br /> Professional Services, ;an;taiv Permit Number(to be filled in by Co.) <br /> RVisEtD Industry Services Division 15A�j Re-/ <br /> i Sanitary Permit Application time 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-awned POWTS are submitted to Project Address(if different than mailing address) <br /> the Depattrment of Safety and Professional Services Personal information%ou provide may be used for secondary <br /> aupo�,c,rims cw hp c'.dill the 1,ri%acy I au' s l j().111)tmn Stair #### Great Bear Ln <br /> 1.Application lnforeEatian--Please Print All Information <br /> Propci tv O\'nci s?Same �' aa 'I_ -I Parcel i1 <br /> Voyager Village POA SI'Yl W cold 4�o�c�,��S LC 07-012-2-40-15-13-5 15-255-064000 <br /> Property Owner's Mailing Address —�� Propem location TaV 'D -1 3 8 ` <br /> G(,28851 KILKARE RD _ .t Lot J� <br /> — <br /> (,ite.Suite II i / �t odc Phone Nunihci <br /> Danbury, WI 54830 _',:, Section,_13 <br /> IL Type of Building(check all that apply) <br /> I.otk T _40 /.N R 15 [10 <br /> ® I or 2 Family 1)wellmg-Number ofBedrooms__..... - 3 54 Subdivision Name <br /> Block u GREAT BEAR ADD TO VOYAGER VILLAGE <br /> 11 Public/Commercial-Describe Use_...__._.__._.... -_.___--.-- <br /> C7 City of.- _ _... <br /> ❑State ONvned-Describe Use _- _ __. ___ CSM Number ❑Village of _ -- <br /> ® rti\\,t t,I Jackson <br /> fl3.Type ofPOW—TS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on Iine$.Comph#e ink C i <br /> 1 New S?stem ❑ Replacement System ❑Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain) <br /> L7 <br /> B. ❑Holding Tank Yin-Ground ❑ At-Grade ❑Mound ❑Individual Site Design ❑Other Type(explain) <br /> (conventional) _ <br /> C. ❑Renewal Before ❑ Revision Change of Plumber i ❑Transfer tt,Sew Chvner� <br /> -ist Previous Permit Number and Date Issued <br /> }'.\,III a1i011 ( j <br /> ,12 ral t Arse and Tank Information: <br /> Design Flow(gpol I Design Soil Application Rate(gpdist) I Dispersal Arca Required(st) Dispersal Area Proposed(sf) System L.levation <br /> 450 ; 0.7 643 675.6 <br /> Capacity in Total 4 of 4lanufacturer <br /> Tank Information Gallons Gallons Units c <br /> Nv Tanks Existing Tanks <br /> Scpw or Holding Tank 1 000 1 1000 1 _-- <br /> Dosing Chwobcr <br /> ' ►t melet h the nndera�ned,assume respoasltuill for i s on of the PCIWTS shown ore the attached plans. <br /> 4inPIU-,ee"�sssN�( riot} ['lumber's Signature 'v P'MPRS Number Busuiess Phone Kumher <br /> A(ldress(Scree ity,Sta ,Zip Code) / �lq <br /> Vt.Goa /De artment Use Only. <br /> permit Fee Date Issued issuing:Agent Signature <br /> approved Uc,dppio�eu <br /> � 0 Owner Given Rmskw; .; Ir,� ,�r <br /> Conditions of Approval/Reasons for Disapproval <br /> M tPior aU X4 s <br /> revisiail. S�N"Zy"�y 'tC> !r�a� <br /> �b11Ow G!a ccx�,rtE-y o Sao rgLutt xAW+S �nE� EWE5 <br /> Attach to complete plan,rot du•s.,stun and suhnot to the('ounh tint,tin paper oat des.,than S is 11 in <br /> � J U N 17 2G24 <br /> tiBl}-6398(R.03r122) U <br /> Burnett County <br /> Land Services Department <br />