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4y, "ar� County <br /> Industry Services Division BURNETT <br /> 1400 E Washington Ave <br /> s SanitaryPermit Number(to be filled in by Co.) <br /> P.O. Box 7162 <br /> yo Madison,WI 53707-7162 8760 <br /> SR4—1& <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govcmmental 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,Stats. 21977 SPIRIT LAKE ACCESS FREDERIC 54837 <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> GREGORY J&MARGARET R CINCOTTA TRUST AGREE 07-034-2-37-I8-12-5 05-001-024000 <br /> Property Owner's Mailing Address Property Location <br /> 21943 MARTIN LK RD NE <br /> Govt.Lot 1 <br /> City,State Zip Code Phone Number /4, /4, Section 12 <br /> STACY,MN 55079 (651)269-7428 (circle one) <br /> T37N; R18WEorW <br /> II.Type of Building(check all that apply) Lot# <br /> ® l or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑State Owned-Describe Use ❑ City of <br /> rc <br /> SM Number ❑ Village of <br /> ® Town of TRADE LAKE <br /> I1I.Type of Permit: Check only one box on line A. Complete line B ifapplicable) <br /> A. ❑ New System ® Replacement System ❑Treatment/Holdin Re <br /> g 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 System/Component/Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized h1-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.Dis ersaVrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 Rate(gpdsf) N/A N/A N/A <br /> N/A <br /> VI.Tank Info Capacity in <br /> Gallons Total #of ami <br /> GallonsUnifs Manufacturer <br /> New Tanks Existing Tanks w i 2 d <br /> U rn Pi, ti w C7 CL <br /> Septic or Holding Tank 2000 2000 1 WIESER CONCRETE ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- 1,the undersign ,a'6eirespoqstfiility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prim) Ph4nbe re MP/MPRS Number Business Phone Number <br /> CORY JACKSON 1 824339 715-566-2786 <br /> Plumber's Address(Street,City,State,Zip Code) n <br /> 9306 BLACK BROOK RD. WEBSTER,WI 54893 <br /> VIII.Coun /De artment Use Only <br /> Approved I ❑ Disapproved Permit Feer O (Daate Issued / Issuing Agent Sign <br /> El Owner Given Reason for Denial $ 4 7J . d -Z10 �OD <br /> DL Conditions of Approval/Reasons for Disapproval <br /> aNK C0c47'1;VV hr P61 /LaN, 1 s XarAi tl RFS- Sys � fE C� E I V E <br /> DN .S�rf1��K <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 tcheun size <br /> BURNETT COUNTY <br /> SBD-6398(R03/14) ZONING <br />