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��paxx4q��;7, County <br /> Industry Services Division Burnett <br /> ^' ® 1400 E Washington Ave <br /> $ 1-t Sanitary Permit Number(to be filled in by Co.) <br /> P S P.O. Box 7162 �n <br /> Madison,WI 53707-7162 1588 nn <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),W is.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy law,s. 15.04(1)(m),Slats. EVERGREEN PATH <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> GEORGE&MARILYN LINDERMAN 07-024-2-39-14-14-2 01-000-01(,CX)o <br /> Property Owner's Mailing Address Property Location <br /> 3740 STACY CIR <br /> Govt.Lot <br /> City,State Zip Code Phone Number ne Y.,nw'/., Section 14 <br /> WHITE BEAR LAKE,MN .551 l0 (circle one) <br /> T39N14; RINE o1W J <br /> IT.Type of Building(check all that apply) Lot# / �� <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms ` Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# K/ <br /> El City of <br /> El State Owned-Describe Use <br /> El Village of <br /> CSMINItm f ® Town of rusk <br /> Vi <br /> [II.Type of Permit: Check only one box on line A. Complete line 8 if applicable) <br /> A. ®New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> W.Type of POWTS S stem/Cotn nent/Device: Check all that apply) <br /> ®Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mounds 24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 Rate(gpdsf) 642.8 652 91.5 <br /> .7 <br /> VI.Tank Info Capacity in <br /> Gallons Total #of 2 u <br /> Gallons Units Manufacturer <br /> New Tanks Existing Tanks U r"n w E5 a <br /> Septic or Holding Tank x 1000 -1 Huffcutt 0 ❑ ❑ ❑ ❑ <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prim) pl m� MPfMPRS Number Business Phone Number <br /> Luke Schmitz /�/" --WiFo ` D 1 884121 715-468-2434 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 160 Shell Lake WI 54871 <br /> VIII.County/Department Use Only <br /> {/Q Approved ❑ DisapprovedPermit Fee OD Date Issued Issuing Agent Signature <br /> Jt Owner Given Reason for Denial $ 7s 7'/( ' M. <br /> IX.Conditions of Approval/Reasons for Disapproval E C E E <br /> JUL9n <br /> 18 2016 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 tri z in size <br /> BURNETT COUNTY <br /> SBD-6398(R03/14) ZONING <br />