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Department of Safety county <br /> BURNETT <br /> & Professional Services, <br /> a Sanitary Permit Number(to be filled in by Co.) <br /> Industry Services Division 3hAl- 7 V _ <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 address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary -Fax �D LOU 00 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I.Application Information-Please Print All Information TREASURE ISLAND ROAD <br /> Property Owner's Name Parcel# �Zy <br /> TIMBERLAND COTTAGES 7-012-2-40-15-13-5 15-246=011000 <br /> Property Owner's Mailing Address Property Location <br /> 19200 CO.RD.40 Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> NE <br /> BELLLE PLAIN, MN 56011 '/<, SW '/<, section 13 <br /> 11.Type of Building(check all that apply) Lot# T 40 N R 15 :� W <br /> IN or 2 Family Dwelling-Number of Bedrooms ____ 3 1 Subdivision Name <br /> Block# VOYAGER VILLAGE <br /> ❑Public/Commercial-Describe Use <br /> NA Cl city of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> NA [#'own 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. <br /> X New System Replacement System Other Modification to Existing System(explain) El Additional Pretreatment Unit(explain) <br /> B. <br /> ❑ Holding Tank X in ground ❑ At-Grade 9A'.../ Individual Site Design Other Type(explain) <br /> (conventional) <br /> C. El Renewal Before El Revision El Change of Plumber El Transfer to New Owner <br /> ist Previous Permit Number and Date Issued <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(sf) System Elevation <br /> 450 0.7 642.86 652 97.00 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units V U <br /> New Tacks Existing Tanks L c CZ <br /> a U rn ti is. C7 a <br /> Septic or Holding Tank <br /> 1000 1000 WIESER COMBO X <br /> Dosing Chamber 650 65fy, 650 <br /> V.Responsibility Statement-I,the undersigned,assume respo sibili for in,,ptallation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sign re 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 Permit F�ejeC19 (Datq Issued Issum gent Signature <br /> \ ❑Owner Given Reason for Denial <br /> Conditions of Approval/Reasons for Disapproval <br /> al s EP,c�e re�u�►�e.► ,r►-fs C� C 0 <br /> neb:9 q <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I I ekA4 size <br /> Burnett County <br /> SBD-6398(R.03/22) <br /> Land Services Department <br />