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""t"'�kT Department of Safety county <br /> BURNETT <br /> & Professional Services, Sanitary Permit Numqer(to be filled in by Co.) <br /> } - Industry Services Division { J-Zq -2`fl <br /> 9 <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 /> I.Application Information-Please Print All Information Z902 'MAJESTIC WAY <br /> Property Owner's Name Parcel# <br /> TODD & VENESSA DECOSSE 7-012-2-40-15-11-5 15-458-018000 <br /> Property Owner's Mailing Address Property Location <br /> 823 106TH STREET Govt.Lot NA Tay- t 2�City,State Zip Code Phone Number <br /> ROBERTS, WI 54023 612-743-7163 '/<, v., Section I I <br /> IL Type of Building(check all that apply) Lot# T 40 N R 15 IW4w <br /> IN or 2 Family Dwelling-Number of Bedrooms 3 .. 8 Subdivision Name <br /> Block# MAJESTIC WOODS <br /> ❑Public/Commercial-Describe Use <br /> NA ❑city of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> NA [Mown 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 /> _— <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 Individual Site Design Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before ❑ Revision ❑ change of Plumber ❑Transfer to New Owner ist 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 0.7 642.86 652 93.00 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units B O T y <br /> New Tanks Existing Tanks c d <br /> a U in ti rA iz <br /> Septic or Holding Tank 1000 1000 1000 1 WIESER X <br /> Dosing Chamber f <br /> V.Responsibility Statement-1,the undersigned,a e r o sibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu s Si a e 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 Perm�iftGFee Date Issued (� Issuing Agent c= ignature <br /> ❑Owner Given Reason for Denial $ 7��/ ZD� I <br /> Conditions of Approval/Reasons for Disapproval 3 � e2 <br /> ku-,+ ao �oback D <br /> �o�IDw G(•U county GYcd S-�� YefGir i�n'�'l� SEP 18 202�t <br /> Burnett Count <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 lAkx 11 trkhW hitiwCeS Uepartment <br /> SBD-6398(R.03/22) <br />