Laserfiche WebLink
County <br /> Industry Services Division Burnett <br /> D 1400 E Washington Ave <br /> S Sanitary Permit Number(to be filled in by Co.) <br /> P� S P.O. Box 7162 <br /> y}r Madison, WI 53707-7162f. <br /> N��ss�cn±�l� CJ t <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Stats. 28269 Tokash Rd <br /> I. Application Information—Please Print All Information - -ay-lb 1$S1 <br /> Property Owner's Name Parcel# <br /> Scott&Renee Thelen 07&8-240-14-24-5-05-006-01700 <br /> Property Owner's Mailing Address Property Location <br /> 97 1541h Ave Nw <br /> Govt.Lot 6 <br /> City,State Zip Code Phone Number /4, /<, Section 24 <br /> Andover,Mn. 55304 763 242-5106 (ciJ;cle one <br /> T40N R14WEorV <br /> I I.Type of Building(check all that apply) Lot# v <br /> ® I or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> ❑ Public/Commercial—Describe Use Block# <br /> El City of <br /> ❑ State Owned—Describe Use <br /> CSM Number ❑ Village of <br /> ® Town of Scott <br /> Ill.Type of Permit: Check onl one box on line A. Complete line B if applicable) <br /> A. ❑ New System ® Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner 12 199 2 <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> ® Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) Add Filter canister and new leachfield <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application__7 Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 Rate(gpdsf) 643 652 97.75'-95.0' <br /> .7 <br /> VI.Tank Info Capacity in <br /> C b U <br /> Gallons Total #of Manufacturer oA� V <br /> Gallons Units = <br /> New Tanks Existing Tanks a U in y ii C7 <br /> Septic or Holding Tank 1000 1000 1 skaw ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber I I I I ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- 1,the undersigned,assunje responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumbe ignatur�re MP/MPRS Number Business Phone Number <br /> Gany Christman 248704 715 416-0373 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> N 10015 Mack Lake Road Trego,Wi.54888 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee - <br /> Dat Isseedd Issuing Agent 'gnature <br /> El Owner Given Reason for Denial $`I�5 5 Wv�5 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> In <br /> ro�low as cou4i-j s*kuk re�u'tr,�m�r�S <br /> APR 2 8 2025 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inch n <br /> Burnett County <br /> SBD-6398(R03/14) Land Services Department <br /> G JfJ0' �lf 2� <br />