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.71` .�RTIry Ll\ Industry Services Division Burnett <br /> County <br /> ,s `�Y,, 4822 Madison Yards Way <br /> �- =' Madison,WI 53705 Sanitary Permit Number(to be filled in by <br /> \,! ; p= P.O.Box 7302 0.) <br /> \�6 � Madison,WI5302 ' 46) <br /> \n,�zmnt� ,2'- <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 is <br /> required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to the Project Address(if different than mailing <br /> Department of Safety and Professional Services.Personal information you provide may be used for secondary address) <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stars. 29741 LONG LAKE TRL <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> ROBERT C MACHGAN 07-032-2-41-16-34-3 02-000- <br /> 014000 <br /> Property Owner's Mailing Address Property Location <br /> 3654 VERMILION CT N TaX,lD <br /> Govt.Lot 1 22251 <br /> City,State Zip Code Phone Number <br /> EAGAN,MN 55122 651-724-8339 <br /> /<, /4, Section 34 <br /> I1.Type of Building(check all that apply) Lot# T 41 N R 16 W <br /> ❑x 1 or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name <br /> PCL GOV LOT 1 SEC 33&NW SW <br /> Block# SEC 34 <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City of <br /> CSM Number 0 Village of <br /> x0 Town of Swiss <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 <br /> if applicable.) <br /> A. <br /> ❑New X Replacement System El Other Modification to Existing System(explain) El Additional Pretreatment Unit(explain) <br /> System <br /> B. ❑ Holding —Eln-Ground ❑ At-Grade Mound ❑ Individual ❑Other Type(explain) <br /> Tank (conventional) Site Design <br /> C. El Renewal El Revision El Change of Plumber ❑ Transfer to New Owner List Previous Permit Number and Date <br /> Issued c <br /> Before Expiration 1LI?O5 <br /> I pI23I�9�y <br /> +l- <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area System Elevation <br /> 300 .7 28 Proposed(sf) 94.5/93 <br /> 52 <br /> Capacity Total #of Manufacture <br /> Tank Information in Gallons Units <br /> Gallons ro <br /> New Existing Tanks <br /> Tanks a v Cn iz 5 G <br /> Septic or Holding Tank x 840 1 Wieser <br /> Dosing Chamber x 500 1 1W <br /> ieser <br /> V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu Si na MP/MPRS Business Phone Number <br /> Luke Schmitz Number 715-520-2434 <br /> 884121 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Po Box 160 Shell Lake WI 54871 <br /> VI.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature Q{4UZI,# ' n I <br /> Approved 0 Disapproved $y2 J air) _ <br /> 0 Owner Given ReasonF Fr <br /> for Denial <br /> �Met� G,U wbu,is , APR 2 8 202.51 0 <br /> wj� W S� �Q W Burnett County <br /> Land Services Department <br />