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Department of Safety County <br /> �.A�i4f.,�, Burnett <br /> & Professional Services, Sanitary Permit Number(to be tilled in by Co.) <br /> Industry Services Division �'N`��—lw3 <br /> T, s--20-55 85! <br /> State Transaction Number <br /> Sanitary Permit Application <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 Protect Address(ifdifferent aX I Ins) <br /> the Department of Safety and Professional Services Personal information you provide may be used for secondary Treasure stand� ,�Terl <br /> purposes in accordance with the I't lca,�� 1��� I (111 1)hn i-Stats L <br /> Lion-Please Print All Information <br /> Parcel 4 <br /> Property Chvner's Name <br /> 07-012-2-40-15-12-5 15-7 50-110000 <br /> Voyager Village POA property Location <br /> Property Owner's Mailing Address <br /> 28851 Kilkare Rd Govt-Lot <br /> City,State Zip Code Phone Number 12 <br /> Danbury, WI <br /> 54830 '/., '/., Section _ <br /> Lot t( T 40 N R 15 E o <br /> 103 Subdivision Name <br /> 0 1 or Family Dwelling-Number of Bedrooms <br /> 3 <br /> Block# TREASURE ISLAND ADO TO VOYAGER VILLAGE <br /> ❑Public/Commercial-Describe Use 0 City of <br /> ❑State Owned-Describe Use __ __ C'SM Number ❑Village of - <br /> Jackson <br /> ®Town of <br /> Ili.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 /> FNew <br /> ❑ Replacement System ❑Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) <br /> nk OO ln-Ground ❑ At Crradc ❑ Mound ❑Individual Site Design ❑Other Type(explain) <br /> (conventional)fore ❑ Revision ❑Chance ofPlumber ❑Transfer to New Owner <br /> ist Previous Permit Number and Date Issued <br /> IV.Dis ersaUTreatment Area and Tank Information: <br /> Design Floss(gpd) Design Soil ApphcaUon Rate(gpd sf) Dispersal,Area Required(sf) Dispersal Area Proposed(st) S}'stern Flesauon <br /> 450 0.7 643 646.6 99.5 <br /> Capacity in Total it of Manufacturer <br /> Tank Information Gallons Gallons Units U <br /> New Tanks Existing Tanks E C. „mod, — <br /> a. <br /> Septic or Holding Tank 1000 Wieser <br /> Dosing Chamber <br /> V.Responsibility Statement- I,the undersigned,assume respon, ility inst ation of the poNyrs shown on the attached plans. <br /> Plumber's Name(Prtnn PlUmbel Signal ff>�� 11 A1Pk��umbrr Iiusines.,i'hure\uinlrr <br /> CD f- `3_Samson - - -- -- �ay3�9 <br /> Plumber's A dress(Street,City.State,Zip Code) <br /> YL_WCoant /De artment-Use Only <br /> i 1'crmit Fcc � [)ate Issued lsrswn Agent Signature <br /> Approved 0 Disapproved 5 ZS00 Lq 1 f^ � <br /> ,� \\ ❑Owner Oven Reason for Dental J tY <br /> Conditions of Approval/Reasons for Disapproval <br /> Iq <br /> lDw c�,u cour��7 o1r� S407k r011 e-V_I LL <br /> nD <br /> E0' F5VF <br /> Attach to complete plans for the system and submit to the County only on parer not less than R V2 s 11 in s e APR <br /> O 8 2024 <br /> SBD-6398(R.03/22) Burnett County <br /> Land Services Department <br />