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x""4`Nr County <br /> Safety and Buildings Division Burnett <br /> ®$ 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> sP Madison,WI 53707-7162 5q I1 La'a <br /> s1gQv) al g <br /> Sanitary Permit Application 2�TransactinnNamber <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit Project Address(if different than mailing address) <br /> is required prior to obtaining a sanitary permit. Note:Application forms for stave owned POWTS are submitted to <br /> the Department of Safety and Professional Semies. Personal information you provide may be used for secondary 9 I S O I �� T_G�Irni✓ 1 r I <br /> purposes in accordance with the PrivacyLaw,s.15. 1 m,Stets. O I <br /> L Application Information-Please Print All Information <br /> Property Owner's Name parcel# <br /> Mike Ehret(Ebert Living Trust DTD 07-034-2-37-18-12-5 15-946-026000 <br /> Property Owner's Mailing Address Property Location <br /> 1830 Interlachen Alcove <br /> Govt.Lot 5 <br /> City,State Zip Code Phone Number Section 12 <br /> Woodbury MN 55125 (arc ) <br /> T37 N; R 18 Eo Wj <br /> U.Type of Building(check all that apply) Lot# <br /> A 1 or 2 Family Dwelling-Number of Bedrooms 5 IS Subdivision Name <br /> Plat of Whispering Pines Spirit Lakee <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Na 11 Town of Trade Lake <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A. ®New System ❑Replacement yst ep System ❑ Trentnsem/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. List Previous Permit Number and Date Issued <br /> ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersalflPreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdct) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 750 1.00 750 752 9&50' <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks V <br /> ie <br /> V) w� a <br /> Septic or Holding Tank 1585 1585 1 Wieser Concrete X <br /> Dosing Chamber 950 950 Combination X <br /> VH.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber' MP/MPRS Number Business Phone Number <br /> Robert Carlson 135655 715-653-2500 <br /> Plumber's Address(Street,City,State,Zip Cale) <br /> 3572 115'St. Frederic W154937 <br /> VTH.CountylDepartment Use Only <br /> Approved ❑Disapproved Permit Fee D O Dale Issued Issuing Agent Signat <br /> ❑Owner Given Reason for Denial <br /> M Conditions of Approval/Reasons for Disapproval InOCT <br /> ECEIVE <br /> 2 6 2016 <br /> Attach to complele plans for the system and sabiait to the County only on paper not lee tlun 8 yr s l l [Ja m sloe <br /> BURNETT COUNTY <br /> ZONING <br />