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rw�i� Department of Safety County <br /> Burnett <br /> & Professional Services, nary Permit f umber to be fined in by Co.) <br /> Industry Services Division Y � <br /> ' if L-1 <br /> Sanitary Permit Application <br /> Ppl ication 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 different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary <br /> rurposes in accordance with the Pnvact La�� 1 fW(I Ilan�.Stats �$ Half M n Clr <br /> I.Application Information—Please Print All Information <br /> Prr,DIern ()%lTIC[ 5 N;imc Parcel k <br /> Voyager Village POA 07-012-2-40-15-13-5 15-270-069000 <br /> Property 0%),ner's Mailing Address --------- --- Property Location <br /> 28851 Kilkare Rd <br /> Govt.Lot <br /> City,State ( "Lip Code Phone Number <br /> Danbury, WI 54830 /•, /., Section 13 <br /> II.Type of Building(check all that apply) I.otif T 40 N R 15 E omw <br /> d ru'_Family DhvL:I me--Nmnbcr„t k( 1 59 Subdivision Name <br /> ❑Public/Commercial—Describe Use <br /> Block a Half Moon Add to Voyager Village <br /> _ <br /> -_ ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> ®Town of Jackson <br /> III.Type of PO\N'TS 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 9New System <br /> y ❑ Replacement System ❑Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) <br /> B' ❑ HoldingTank Mil-Ground ❑ At-Grade g ❑ Other Type(explain) <br /> Mound ❑Individual Site Desi n <br /> (conventional) <br /> C. ❑Renewal Before ❑ Revision ❑ Chanac of Plumher ❑Transfer to New Owner ist Previous Permit Number and Date Issued <br /> Expiration IL <br /> W.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Apphcauon Rate(gpd si) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 450 0.7 643 646.6 95 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units o $ u <br /> New Tani., Existing I..:,,s u c v 2 <br /> a U s H In <br /> Selma or holding Tank 1000 1000 <br /> 1 Wieser <br /> V.Responsibility Statement- 1,the undersigned,assume respwrisibilo for i allation of the PORTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber s Sty re vtl'lMPRS Nmnbcr Business Phone dumber <br /> Cory J. Jackson 824339 715-566-2786 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 24884 State Rd 35 Siren, WI 54872 <br /> VI.Count'LDe artment Use Only <br /> Approved ❑Disapproved ' Permit Fee Dat Ilssu d Issuing Agent Signature <br /> ❑Oumer Given Reason for DentalS <br /> Conditions of Approval/Reasons for Disapproval <br /> now (� Co�,in-�( and S4k rqW rfw" -5 <br /> DD <br /> V E I nil <br /> Attach to complete plans for the system and submit io the County only on paper not less than 8 1/2 11ar es itt.Pt'U` <br /> 2024 <br /> SBD-6398(R.03/22) AA L L <br /> Burnett County <br /> Land Services Department <br />