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Department of Safety c°°`'ty BURNETT <br /> _ & Professional Services, Sanitary Permit Number(to be filled in by Co.} <br /> Industry Services Division �' Z1� _ z 7 <br /> =V C <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 <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I.Application Information-Please Print All Information 22617 AKERMARK ROAD <br /> Property Owner's Name Parcel# U5-po 5 <br /> MARLIN & LEAH OLSON 7-042-2-38-18-34-56 018000 <br /> Property Owner's Mailing Address Property Location l�. 21 561 <br /> 15060 FREDERICK ROAD Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> RODGERS, MN77:�: 55374 /<• '/4, Section 34 <br /> II.Type of Building(check all that apply) Lot# T 38 N R 18 w <br /> EY1 or 2 Family Dwelling-Number of Bedrooms 3 2 Subdivision Name <br /> Block# NA <br /> ❑Public/Commercial-Describe Use <br /> NA ❑city of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> V 14,P 181 EKown of WOOD RIVER <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. New System X Replacement System Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain) <br /> B. El Holdingground Holding Tank in ❑ At-Grade W—/ Individual Site Design Other Type(explain) <br /> add filter <br /> C. El Renewal Before [I Revision ❑ Change of Plumber ❑ Transfer to New Owner <br /> ist Previous Permit Number and Date Issued <br /> Expiration <br /> Zo_M <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sO Dispersal Area Proposed(sf) System Elevation <br /> 450 0.7 642.86 650 93.00 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units L U N <br /> New Tanks Existing Tanks c ° p i -S <br /> a U in cn ii C7 Ci. <br /> Septic or Holding Tank 1000 1000 1 WIESER X <br /> Dosing Chamber <br /> V.Responsibility statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PlutllUer's Signature YIP/MPRS Number Business Phone Number <br /> BRIAN SANDSTROM At Q&i 715-553-8809 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 2911 200TH STREET,LUCK,WI 54853 <br /> V1.County/Department Use Only <br /> Approved El Disapproved Per22mit Fee Date/Issu/edm(� Issuing ent Signature <br /> El Owner Given Reason for Denial ` 101�v�'/ <br /> Conditions of Approval/Reasons for Disapproval <br /> �►�ow aJJ cCan.+Y cnd s*x-k ✓efui its <br /> lnus-� hM 3 0� Sui- sot i 4tQ 5rstin -tlevahia D <br /> N IAN 0 3 2024 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 h size <br /> Burnett County <br /> SBD-6398(R.03/22) Land Services Department <br />