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AMTttt Count <br /> Department of Safety Burnett <br /> Ili �K• & Professional Services, Sanitary Permit Ntunber(to be filled in by Co.) <br /> See Revlsl 11 Industry Services Division �>v _4zLf <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 <br /> is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address if difTerent than mailing address) <br /> the Department of Safety and Professional Services Personal information you provide may be used for secondary <br /> pur,,nses in,tc� i&ncc wth the Pr, I axN , I;nd(1)(Uri).Statti Great Bear Ln <br /> 1.Application Information—Please Print All Information <br /> ('rupern thcm•r s Name Parcel# <br /> Voyager Village POA 07-012-2-40-15-13-5 15-255-064000 <br /> Property Owner's Mailing Address Property Location <br /> 28851 KILKARE RD <br /> Gout.Lot <br /> City,State Zip Code Phone Number <br /> Danbury, WI 54830 /.,_ section 13 <br /> _o tt*AI►IY) I.ot# T 40 N R 15 E criM <br /> * 1 or 2 Family Dwelling—Number of Bedrooms 3 54 Subdivision Name <br /> Block# GREAT BEAR ADD TO VOYAGER VILLAGE <br /> O Public/Commercial—Describe Use <br /> O City of <br /> O State Owned—Describe Use is SM Number ❑Village of <br /> ®Town 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 i <br /> applicable.) <br /> A. YNew System <br /> y ❑ Replacement System ❑Other Modification to Existing System(explain) El Additional Pretreatment Unit(explain) <br /> B. ❑Holding Tank 91n-Ground ❑ At-Grade g Type( xp❑ Mound ❑ Individual Srtc Design ❑Other T (explain) <br /> (conventional) <br /> C. ❑Renewal Before 1 ❑Revision ❑Change of Plumber ist Previous Permit Number and Date Issued <br /> ❑ Trtn;fcr to New(honer <br /> Expiration IL <br /> ff'.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Raie(gpd sl) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 450 0.7 643 675.6 96 <br /> Capacity in Total N of Manufacturer <br /> Tank Information Gallons Gallons Units u o <br /> U <br /> N <br /> New Tanks Existing Tanks 2 <br /> = j in q CA rz 3 CL <br /> Septic or Holding Tank 1000 1000 1 Wieser X _ <br /> nosing Chamber 600 600 1 Wieser • <br /> V.Responsibility Statement- I,the undersigned,assume resp ibili or itijAll.firin of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumbers Sign re MI1A4PRS Number Business Phone Number <br /> Cbr S. �GIC�k..So`f1 �A 32)0\ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> a�ggy � }-tie 2-a <br /> Vl.cQua Ille etenent Use Only <br /> Approved ❑Disapproved Permit Feed Dal Issu d Issuin Agent Signature <br /> ❑Owner Given Reason for Denial � z'! <br /> Conditions <br /> ,�nlI of�A/�ppp�roval/Reasons for <br /> Disapproval <br /> AL L <br /> R <br /> Attach to complete plans for the system and submit to the County only on paper not less than g it2 x 11 i. es i EJ <br /> ize <br /> SBD-6398(R.03/22) Burnett County <br /> See Revision Land Services Department <br />