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commerce.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> iMadison,WI 53707-7162 Sanitary Permit Ni either(to be filled in by Co.) <br /> seonsin <br /> Dapartment of commerce <br /> Sanitary Permit Application State Tia exaction I lumber <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental / l)b 2 <br /> unit is required prior to obtaining a sanitary permit. Note: Application fortes for state-owned POWTS are Project Address(it different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary p�� ,, <br /> purposes in accordance with the PrivacyLaw,s.15.04 1 (m),Stats. 22845 Carey Nater Rd <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Neil & Carol Martin rp 042-2525--08 000 �) <br /> Property Owner's Mailing Address Property Location r <br /> 11785 F 1 etcher Lane Govt.Lot <br /> City,State Zip Code Phone Number /, V.., Section 91; _ <br /> Rngers MN 155374 763-428-2711TSN 08(circle on <br /> II.Type of Building(check all that apply) Lot# <br /> 3 Subdivision Nam <br /> lor2 Family Dwelling-Number of Bedrooms 1167 Vnl 15 Pg 344-345 <br /> Block# <br /> D Public/Commercial-Describe Use D City of <br /> CSM Number D Village of <br /> El State Owned-Describe Use <br /> Qff.wnof-Wo)d River <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. s((New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modifici tion to Existing System(explain) <br /> B. D Permit Renewal D Permit Revision D Change of Plumber D Permit Transfer to New List Previous Pen tit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> D Non-Pressurized In-Ground D Pressurized In-Ground D At-Grade (Mound>24 in.of suitable soil D Mound<24 i i.of suitable soil <br /> D Holding Tank D Other Dispersal Component(explain) D Pretreatment Device(explain) <br /> V.Dispersal/Treat ent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) mall Ar.Required(st) Dispersal Area Proposed(st) System Elevation <br /> JIAJ <br /> VI.Tank Info Capacity in Total #of Manufacturer o _ <br /> L <br /> Gallons Gallons Units Xd U y <br /> New Tanks Existing Tanks p °= 2 y a <br /> U y N ti W C7 6. <br /> Septic or Holding Tank 1 __ <br /> Dosing Chamber <br /> VII.Responsibility Statement- <br /> 11111,the undersigned,a me Z11i inatallati of[he POWTS shown on the attar ed plans. <br /> Plumber's Name(Print) Put e s SigVMP/MPRS NumberBusiness Phone Number <br /> Dayton R Daniels MUM 7 - <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 316 Siren WT 54,972 <br /> VIII.Court /De artment Use Ont <br /> P( <br /> Permit Fee Date Issued issuing A.gentSignamrc <br /> Q Approved D Disapproved `t f <br /> ❑Owner Given Reason for Denial $ <br /> .-, ) 3.t-/ Q 1 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> D ISI <br /> JULal 2007 U <br /> Attach to complete plans for the system and submit to the County only an paper eat less 1 a /i x I1 inches i slu <br /> BURNETT COUNTY <br /> SBD-6398(R.01/07)Valid thm 01/09 Z NTNG <br />