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. 0T�,�Nr Department of Safety County BURNETT <br /> & Professional Services, <br /> Sanitary Permit Number to be filled in by Co.) <br /> Industry Services Division RN''t2L1-23�{ <br /> C -Q 1941 <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 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. �q�q <br /> I.Application Information—Please Print All Information 2!U 13 DEERPATH PASS <br /> Property Owner's Name Parcel# <br /> TIMBERLAND COTTAGES 7-012-2-40-15-10-5 15-128-208000 <br /> Property Owner's Mailing Address Property Location g <br /> 19200 CO.RD.40 Govt.Lot NA Q X D v 4 <br /> City,State Zip Code Phone Number <br /> BELLLE PLAIN, MN 56011 952-994-6924 %, %, Section 10 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 15 �bXw <br /> IN or 2 Family Dwelling—Number of Bedrooms----- ___3 199 Subdivision Name JC n„ea I/_ /�,t J y <br /> Block a VOYAGEIRVI LAGE �C? <br /> ❑Public/Commercial—Describe Use <br /> NA ❑City of <br /> ❑State Owned—Describe Use -- CSM Number ❑Village of <br /> NA Ekown 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) ❑ Additional Pretreatment Unit(explain) <br /> B' ❑ Holding Tank X in ground ❑ At-Grade Individual Site Design Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration <br /> IV.DispersaL/TreatmentArea 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 0.5 900 932 98.00 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units U L, N <br /> New Tanks Existing Tanks Y s "y <br /> Septic or Holding Tank 1000 1000 1000 1 WIESER X <br /> Dosing Chamber <br /> V.Responsibility Statement-I,the undersigned,assume respyrsibil,#for i tallation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sig 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 Flee �Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial $ 7Z> <br /> Conditions of Approval/Reasons for Disapproval <br /> how 0 a C� Cnd S-fie rP u ir;✓m-e-��S D <br /> � <br /> P1 i SEP 0 3 2024ID I <br /> Attach to complete plans for the scstem and submit to the County only on paper not less than 8 1/2 it 11 inch�=tment <br /> SBD-6398(R.03/22) <br />