Laserfiche WebLink
.at <br /> Department of Safety county Burnett <br /> 1`r & Professional Services, Sani Permit tun r to be filled in by Co.) <br /> " Industry Services Division -3V <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis. Adm.Code,submission ofthis 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 Seivices-Personal information you provide may be used for secondary <br /> purposes in accordancc tcrih the I'l n ac) I_nk . 1�OJ(I)(mt.Ntats 26685 County Rd H <br /> 1.Application Informnstioe— 'lease Print All Information <br /> Propem Chcne, s Nanic Parcel# <br /> Tax lb 3(0'743 <br /> Mark A. & Madelline Gibbs 07-024-2-39-14-09-5 05-002-011200 <br /> Property Owner's Mailing Address Property Location <br /> 2617 Lowry Ave NE Govt.Lot W 580'gov lot 2 <br /> City,State Zip Code Phone Number <br /> St Anthony, MN 55418 ___ .__ v., Section 09 <br /> �. &*tapply) Lot# -1 39 N R 14 E oM <br /> 0 1 or 2 Family Dwelling-NumberofBedrooms 3 Subdivision Name <br /> Block k <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use <br /> -- — -- CSM Number ❑Village of <br /> V Town of Rusk <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 i <br /> applicable.) <br /> WNc,,+System ❑ Replacement Nxstem ❑ Othe,Mod,Iication to I.xistinsS%stem(cyplami ❑ Additional Pretreatment knit(explain) <br /> B. ❑Holdin Tank gin-Ground ❑ At-Grade ❑ Mound ❑Individual Site Design ❑Other T p <br /> g tSn Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before ❑ Revision ❑Change of Plumber ❑Transfer to Next Owner List Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dis ersainfrextmeat Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpolst) Dispersal Are,Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 0.7 643 646.E 1 94 <br /> Capacity in Total k of Manufacturer <br /> Tank Information <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks �' u <br /> Septic or Holding Tank 1000 1000 1 Wieser <br /> Dosing Chamber <br /> V.Responsibility Statement- 1,the undersigned,assume responsibili for ins illation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signa c MP/MPRS Number Business Phone Number <br /> C.or 5. �o.�1�so� �2.y33`t �ls-s��o-algb <br /> Plumber's ddress(Street,City,State,Zip Code) <br /> YIaESjggAftRAgMSLtKsc Only <br /> Approved ❑Disapproved I Pennn 1 ce� Da[ I5st ed Issuing Agent Sienature <br /> Clow�nerGiven Rc—on for Dental � <br /> Conditions of Approval/Reasons for Disapproval <br /> nnL�aN qu Lour a�' s-�-� ►�e�u'r>�no-� E ..�2 <br /> cEiv C � <br /> Attach to complete plans for the system and submit to the County only on paper not less than R 1/2 x n in - i r' <br /> SBD-6398(R.03/22) BUMP^c1;nty <br /> Land Servicez-llepartmerd <br />