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Department of Safety County <br /> & Professional Services, BURNETT <br /> � San' PerQvt Number(to be filled in by Co.) <br /> P S <br /> Indust Services Division � -?l11a <br /> Cam- 4 -1'7 a <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. <br /> ][.'Application Information-Please Print All Information OVERLAND CIRCLE Zb <br /> Property Owner's Name Parcel# . <br /> MASON&SOFIA SHOEN 07-012-2-40-15-23-5 15-560-059000 <br /> . <br /> Property Owner's Mailing Address Property Location <br /> 16639 18TH STREET S Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> LAKELAND, WI 55043 218-910-0267 i., v., Section 23 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 15 <br /> EYJ or 2 Family Dwelling-Number of Bedrooms 3 _ 49 & 50 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 E&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. ❑ Holding Tank X in ground ❑At-Grade 7iS'..✓ Individual Site Design Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner rst Previous Permit Number and Date Issued <br /> Expiration <br /> IV.DispersaUTreatment 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 0.7 642.86 650 94.00 FT. <br /> Capacity in Total #of Manufacturer Y <br /> Tank Information Gallons Gallons Units c <br /> New Tanks Existing Tanks y y y E� <br /> o`. U <br /> Septic or Holding Tank 1000 _}000^ 1000 1 WIESER X <br /> Dosing Chamber <br /> V.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signa 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 <br /> Fee Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial <br /> Conditions of Approval/Reasons for Disapproval <br /> LO-k y9 4. SO -1 o 6e co,,Vl ned w a Ce r-�i-�-i ed Sunny map 6sm) <br /> t2 31I2p2y DE C F VIE r <br /> Rftp cU cou-n CR8 S+P- R <br /> Ye u I(C,0U-,rA -S AUG 2 6 2624 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 aches in size Burnett County ' <br /> Land Services Department <br /> SBD-6398(R.03/22) <br />