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frle„NrA„tr,4 Department of Safety County <br /> BURNETT <br /> I 1= & Professional Services, Sanitary Permit Number(to be filled in by Co.) <br /> yl Industry Services Division S'AM oZ3? <br /> Sanitary Permit Application State ransactionNumber <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 6264 PIKE BEND ROAD <br /> Property Owner's Name Parcel Number <br /> BENJAMIN HIKES 07-0/8-2-39-16-26-4 01-000-016000 <br /> Property Owner's Mailing Address Property Location <br /> 288 E. SUMMIT AVENUE Govt Lot NA <br /> City,State Zip Code Phone Number <br /> ELLSWORTH, WI 54011 651-214-2732 NE 1/a, SE Vs, Section 26 <br /> II.Type of Building(check all that apply) Lot# T 39 N R 16 W)fiK <br /> 14 1 or 2 Family Dwelling—Number of Bedrooms 2 NA Subdivision Name <br /> Block# NA <br /> ❑Public/Commercial—Describe Use <br /> NA 0 City of <br /> ❑State Owned—Describe Use O Village of <br /> CSM Number X Town of <br /> MEENON <br /> NA <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 i i <br /> applicable.) <br /> A' New System X Replacement System Other Modification to Existing System(explain) Additional Pretreatment Unit <br /> B. Holding Tank x In-Ground (GEOMAT) At- Mound Individual Site Design Other Type <br /> (conventional) Grade fexplain) <br /> I I List Previous Permit Number d Date <br /> C. Renewal Before Revision Change of Plumber Transfer to New Owner <br /> Expiration Issued NK 1 Vtl <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/st) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 Xr- 2. .c) 150 162.50 97.02 FT. <br /> Capacity in Total #of Manufacturer B <br /> Tank Information Gallons Gallons Units <br /> New Tanks Existing Tanks 1 QV0,, (A y n_ <br /> U •pA in2 CLV <br /> Septic or Holding Tank X <br /> 840 840 1 WIESER (combo) <br /> Dosing Chamber 500 500 <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 Sign re MP/MPRS Number Business Phone Number <br /> BRADY UTGARD '3 .. 220357 715-760-0946 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 798 80TH AVENUE,AMERY,WI 54001 <br /> VI.County/Department Use Only <br /> Approved Disapproved Permit Fee Date Issued Issuing Agent Si <br /> $21Z5 ID/211 ZOZ Aidelbp <br /> ❑Owner Given Reason for Denial � <br /> Conditions of Approval/Reasons for Disapproval <br /> Ailee,+ ar t Se- -ba.c.k-S Ct V51.1. 4-42"J.. <br /> follow ail Ca,IMA-I avtcl S- u <br /> . re re_wto rt+S �:: , .� I V <br /> I <br /> � , <br /> I° OCT 24 2025 !� <br /> A'Attach to complete plans for the system and submit to the County only on paper not less than 8 t/2 x . inch in size m j <br /> Burnett County <br /> SBD-6398(R.03/22) Land Services Department <br />