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Department of Safety County <br /> ` & Professional Services, BURNETT <br /> D S 1.5 Sanitary Permit Number(to be filled in by Co.) <br /> Fgf Industry Services Division S�j.. -bci <br /> X.. c5-r- 25 -- f btu 1 l o <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 28101 ELLIS DRIVE <br /> Property Owner's Name Parcel# Tax ID: 33713 <br /> MICHAEL J. & SARA L. AXIOTIS 07-028-2-40-14-20-5 05-004-028100 <br /> Property Owner's Mailing Address Property Location <br /> 6020143RD LANE NW Govt.Lot 4&5 <br /> City,State Zip Code Phone Number <br /> RAMSAY, MN 55303 763-442-4589 v., /, Section 20 <br /> II.Type of Building(check all that apply) Lot# T 40 N R i`I W <br /> IN or 2 Family Dwelling—Number of Bedrooms 4 NA Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use -- <br /> NA ❑City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of <br /> NA l 'ow SCOTT <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.)A. <br /> New System X Replacement System Other Modification to Existing System(explain) Additional Pretreatment Unit(explain) <br /> B. At- <br /> ..I Individual Site Design Other Type(explain) <br /> Holding Tank x in ground (GEOMAT) <br /> (conventional) Grade <br /> C. Renewal Before Revision Change of Plumber Transfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration NK 1V <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 �Q <br /> 600 2.0 300 325 -49 6'0— FT. o ' <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units i. o 'O <br /> New Tanks Existing Tanks d S d t y 10 <br /> 4' U co s in ir. 0 a. <br /> Septic or Holding Tank <br /> 1200 1200 1 WIESER (COMBO) X <br /> Dosing Chamber 800 800 <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 Signa e 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 /> Permit Fee Date Issued Issuing Agent Signature <br /> Approved El <br /> X $❑Owner Given Reason for Denial 25� 5I f ZD�LS ?/# 2/25.U U <br /> Conditions of Approval/Reasons for Disapproval IllOWI Edeo Se0In1eS pups <br /> N A- S- -t WS iciunoo lining <br /> iv LLow cua c bw�-4 and S -I-e v2tu.i a-mem--5IT H <br /> p A W <br /> a) ic✓ fv / G �'► t 4(fl . <br /> - 1 Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size <br /> SBD-6398(R.03/22) <br />