Laserfiche WebLink
Department of Safety County <br /> p & Professional Services, <br /> BURNETT <br /> S Sanitary Permit Number(to be filled in by Co.) <br /> PS 1 Industry Services Division <br /> 5Aov`)'5-3V� <br /> 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(1)(m),Stats. <br /> I.Application Information-Please Print All Information 28648 GREAT BEAR TRCE <br /> Property Owner's Name Parcel# Tax ID: 7344 tQ � <br /> KELLEN &KATHY CHRISTENSEN 7-012-2-40-15-13-5 15-255-0-4000 <br /> Property Owner's Mailing Address Property Location <br /> 706 97th LANE NE Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> BLAINE, MN 55434 /4, %, Section 13 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 15 W <br /> El or 2 Family Dwelling-Number of Bedrooms- _. 3 _ 9 Subdivision Name GREAT BEAR ADDN <br /> Block# VOYAGER VILLAGE <br /> ❑Public/Commercial-Describe Use _ <br /> NA ❑city of <br /> ❑State Owned-Describe Use ____ (Snt Number ❑Village of _ <br /> NA Ekow JACKSON <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on sine A. Check one box on line B.Complete line C i <br /> applicable.) <br /> A. <br /> LX New System Replacement System Other Modification to Existing System(explain) Additional Pretreatment Unit(explain) <br /> B. Holding Tank X in ground At- Individual Site Design Other Type(explain) <br /> (conventional) Grade <br /> C. Renewal Before Revision Change of Plumber Transfer to New Owner List 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(st) System Elevation <br /> 450 0.7 642.86 652 96.00 FT. <br /> Capacity in Total #of Manufacturer y <br /> Tank Information Gallons Gallons Units a c <br /> New Tanks Existing Tanks = d a <br /> a V yr y yr w <br /> Septic or Holding Tank 1000 1 X <br /> 1000 WIESER <br /> Dosing Chamber <br /> V.Responsibility Statement- I,the undersigned,assume resp sibili for in <br /> ptallation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sign 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 /> -proved ❑Disapproved Permit Fee Date Issue7d�w.�� Issuin Agent Sign ure <br /> $ <br /> ❑Owner Given Reason for Denial <br /> Conditions of ApprovaUReasons for Disapproval <br /> c1 <br /> � <br /> U <br /> APR 15 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x inches in s4gurnett County <br /> Land Services Department <br /> SBD-6398(R.03/22) <br />