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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 vAN 45-_6-3 <br /> C37--2.-'3 ( /99 <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.I.Application Information-Please Print All Information u 13 s3 DEERPATH ROAD <br /> Property Owner's Name Parcel# Tax ID: 6907 <br /> AJAY KHOBRAGADE (TIMBERLAND COTTAGES) 07-012-2-40-15-10-5 15-128-224000 <br /> Property Owner's Mailing Address Property Location <br /> 19388 HARMONY AVENUE Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> ROGERS, MN 55374 '/, '/., Section 10 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 15 'E btW <br /> LX or 2 Family Dwelling-Number of Bedrooms __ 3 215 Subdivision Name beeg.94.0 A-p D Tp <br /> Block# VOYAGER VILLAGE <br /> o Public/Commercial-Describe Use <br /> NA ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> NA C{fown 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) 0 Additional Pretreatment Unit(explain) <br /> B. ❑ Holding Tank x in ground ❑ At-Grade ff.../ Individual Site Design Other Type(explain) <br /> (conventional) <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(sf) System Elevation <br /> 450 0.7 642.86 646 97.00 FT. <br /> Capacity in Total #of Manufacturer y <br /> Gallons Gallons Units E o <br /> Tank Information w b y y <br /> New Tanks Existing Tanks a> G : B d ?.5? ,5 <br /> 0 <br /> w U inn w cn w (7 a. <br /> Septic or Holding Tank 1000 _-}gg)—_. 1000 1 WIESER x <br /> Dosing Chamber <br /> V.Responsibility Statement-I,the undersigned,assume respo sibili for in nation 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 /> Approved ❑Disapproved Permit FeeDate <br /> Issued Issuing Agent S. ature <br /> El Owner Given Reason for Denial $�2`�` /7)Z02'5 `v lag �� J�.,� 06 <br /> Conditions of Approval/Reasons for Disapproval I�� r , <br /> D) ttG_._1 _,., V rU <br /> Low ag CO +i aid S-FG1k rq f I iforimil <br /> i l. v '� "�._ <br /> __ ,T;_ ____ <br /> _) <br /> Burnett County <br /> L.7nd Sorvicos DepPrtrront <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 14 iaohes-in-eiae---- -. <br /> SBD-6398(R.03/22) <br />