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ON COM <br />'„`, <br />ervices Division <br />Burnett <br />CountyLITER/ <br />in ton Ave <br />9 <br />P.O. Box 7162 <br />Sam ry Pemrit Number (to be filled in by Co.) <br />��� <br />SIN <br />Madison, W1 53707-7162 <br />�E'c5K>�_ay <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(2), Wis. 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 />Project Address (if different than mailing address) <br />d <br />f d <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />27965 Lone Pine <br />purposes in accordance with the PrivacyLaw, s. 15.04(1)(m), Stats. <br />I. Application Information — Please Print All Information <br />Property Owner's Name <br />Parcel # <br />07-020-2-40-16-29-5 05-001-020000 <br />William Lunzer <br />Property Owner's Mailing Address <br />Property Location <br />2979 Pitrina Way <br />Govt. Lot 1 <br />''% '/4, Section 29 <br />City, State <br />Zip Code Phone <br />Number <br />Little Canada, MN <br />7 <br />55117 651483-6142 <br />(circle one) <br />T40N R16EorW <br />II. Type of Building (check all that apply) Lot <br /># <br />® I or 2 Family Dwelling — Number of Bedrooms 3 1 <br />Subdivision Name <br />❑ Public/Commercial — Describe Use Block <br /># <br />❑ City of <br />❑ State Owned — Describe Use <br />El Village of <br />CSM <br />Vol. <br />Number <br />2 Pg. 207 <br />® Town of Oakland <br />III. <br />Tvoe of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />❑ Replacement System <br />® Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />B. <br />Before Expiration <br />Plumber <br />Owner <br />f 0//0 /y(p s��10 S3S 7 y2a•92 <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. Dispersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />450 <br />Rate(gpdsf) <br />VI. Tank Info <br />Capacity in <br />C <br />Gallons <br />Total <br />Gallons <br /># of ManufacturerU <br />Units <br />c <br />- <br />New Tanks Existing Tanks <br />a U vz y <br />Ln <br />u; 0 <br />a <br />Septic or Holding Tank <br />2000 <br />2000 <br />1 Wieser <br />® ❑ <br />❑ <br />❑ <br />❑ <br />Dosing Chamber <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />VII. Responsibility Statement- I, the undersignedAsumeespopjpibljjty for instg#ation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />PI Is <br />MP/MPRS Number <br />Business Phone Number <br />/ <br />Daniels Plumbing& HeatingInc <br />(/,�L <br />007086 <br />715-349-5533 <br />Plumber's Address (Street, City, State, Zip Code) <br />24056 State Rd 35/P.0. Box 326, Siren, WI 54872 <br />VIII. County/De artment Use Only <br />Approved <br />El Disapproved <br />Permit FeeG� <br />Date Issued <br />Issuing Agent Signature <br />C3Owner Given Reason for Denial <br />$ 37s'. <br />lo— 17 1 7 <br />IX. Conditions of ApprovaUReasonsfnr Disapproval ECEPSE <br />OCT 10 2017 <br />..........., ..,...,,..... ,......., .,............ ......,.,....y .....,, .,.. r..r.,...... ..,.,......... ., .,.........,W Va.— %-00 <br />BURNETT COUNTY <br />SBD -6398 (R03/14) ZONING <br />