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Department of Safety county <br /> BURNETT <br /> Perms& Professional Services, <br /> anrtary Number(to be filled in by Co.) <br /> Industry Services Division ) <br /> ��`' =��- <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 different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. yTl 3 SETTING SUN DRIVE <br /> I.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# " ox L D 9($, <br /> VOYAGER VILLAGE POA(BUYER: DHI HOLDINGS LLC) - <br /> Property Owner's Mailing Address Property Location <br /> 28851 KILKARE ROAD Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> DANBURY, WI 54830 / v., Section 09 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 15 y w <br /> M or 2 Family Dwelling—Number of Bedrooms 3 80 Subdivision Name <br /> Block# VOYAGER VILLAGE <br /> ❑Public/Commercial—Describe Use <br /> NA ❑city of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> NA Ckown 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 /> r.N ew System Replacement System Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain) <br /> B. ❑ Holding Tank in ground ❑ At-Grade x 9/'...1 Individual Site Design Other Type(explain) <br /> fl(conventional) ter <br /> C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner List 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 2.0 225 325 98.00 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units $ y <br /> New Tanks Existing Tanks 0 <br /> aU rn H ann wC7 Q <br /> Septic or Holding Tank 1000 1000 1 WIESER (COMBO) X <br /> Dosing Chamber 650 X <br /> 650 <br /> V.Responsibility Statement- I,the undersigned,assume resp#sibi9f for' tallation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si re MP/MPRS Number Business Phone Number <br /> CORY J. JACKSON 824. 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 Fee Date Issued Issuing Agent Signature <br /> ❑Owner Given Reaso al <br /> Conditions of Approval/Reasons for Disap val' <br /> p I-C,6 <br /> APR 0 8 2024 <br /> Attach to complete plans for the system and submit to the County only on paper not less tha 8 1/2 x 11 inetp'hoteounty <br /> Land Services Department <br /> SBD-6398(R.03/22) <br />