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Department of Safety COUnty <br /> & Professional Services, BURNETT <br /> Sanitary Permit Number(to be filled in by Co.) <br /> Industry Services Division 5'AA)-25-6—a <br /> C57-25--q_z voa 192 <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 (SAME) <br /> Property Owner's Name Parcel# Tax ID: 5788 <br /> RODNEY &JANET HECKMAN TRUST 07-012-2-40-15-28-1 02-000-012000 <br /> Property Owner's Mailing Address Property Location <br /> 4755 C.T.H.A Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> WEBSTER, WI 54893 612-802-8496 ''A, 'A, Section 28 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 15 btW <br /> or 2 Family Dwelling-Number of Bedrooms 3 NA Subdivision Name <br /> Block# NA <br /> ❑Public/Commercial-Describe Use <br /> NA ❑City of <br /> 0 State Owned-Describe Use CSM Number 0 Village of <br /> NA [X'own 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 /> A. <br /> X New System Replacement System Other Modification to Existing System(explain) Additional Pretreatment Unit(explain) <br /> TANK REPLACEMENT&ADDING TO SYSTEM <br /> B. 0 Holding Tank x in ground At- !G../ 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 <br /> Expiration Issued 254040/04-29-96 'ff"J 1 30? <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 0.7 642.86 656 94.50 FT. <br /> Capacity in Total #of Manufacturer Y <br /> Tank Information Gallons Gallons Units <br /> p S U <br /> New Tanks Existing Tanks `,_ y .2 a K1 <br /> a L) rn rn u. 0 a. <br /> Septic or Holding Tank 1000 1000 1000 1 WIESER X <br /> Dosing Chamber <br /> V.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signatur 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 Permit Fee Date Issued Issuing <br /> �Agent Signature Q <br /> ❑Owner Given Reason for Denial $1 25a-22 5/ I2025 -411 tAA-c FILae-`--)5,)q pv t� ` VA C <br /> Conditions of Approval/Reasons for Disapproval <br /> Ik- C U Sc.-Nock b nECE[IVEq <br /> Altow art. l cnd S-iu-1-e require-at rkS ( `, APR 2 a rt2'5tiExis-1 ni) F be ctiNtnf�(!' Burnett County <br /> kand�6crvicoe D�rartma <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 a t s.� �o <br /> SBD-6398(R.03/22) <br />