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tART!/� Department of Safety County <br /> & Professional Services, BURNETT <br /> s Sanitary Permit Number(to be filled in by Co.) <br /> � Industry Services Division —.2q, W-1 <br /> �uc 5T-20- 1 <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(l)(m),Slats. <br /> I.Application Information-Please Print All Information 28991 W. YELLOW RIVER RD <br /> Property Owner's Name Parcel# <br /> THOMAS M. & ELIZABETH C. FLUERY TAX ID: 14379 <br /> Property Owner's Mailing Addres Property Location <br /> Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> COTTAGE GROVE, MN 55016 612-322-9082 V' ��•, Section 07 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 16 �r <br /> IN or 2 Family Dwelling-Number of Bedrooms 2 __ 32 Subdivision Name <br /> Block# RIVER OAKS <br /> ❑Public/Commercial-Describe Use <br /> NA ❑city of _ <br /> ❑State Owned-Describe Use ('SNI Number ❑Village of <br /> N Ekown of OAKLAND <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. X New System Replacement System XOther Modification to Existing System(explain) Additional Pretreatment Unit(explain) <br /> B. ❑ Holding Tank X in ground ❑ At-Grade 915-1 Individual Site Design Other Type(explain) <br /> (conventional) add filter <br /> C. ❑ Renewal Before ❑ Revision ❑Change of Plumber ❑ Transfer to New Owner ist Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dispersat/Treatn Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 300 0.7 428.58 452 95.00 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units a ? o <br /> New Tanks Existing Tanks y d a p <br /> a U in tys &0 <br /> Septic or Holding Tank 750 750 1 WIESER X <br /> Dosing Chamber <br /> V.Responsibility Statement-I,the undersigned,assume respgnsibilijy for i tallation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si a 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 FEIDisapprovedPermit Fee Date Issu d Issuing Agent Signatuner Given Reason for Denial $ <br /> Conditions of Approval/Reasons for Disapproval _ <br /> mkt,+ au �2ac, C Cc� IV IE <br /> f6 a u ccx�n � She MVk1r <br /> ��`/ JUN 10 I'll <br /> Burnett Count <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 incdArtd6ervices Department <br /> SBD-6398(R.03/22) <br />