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/�yAP7M�;�T <br />Industry Services Division <br />County <br />Burnett <br />Sanitary P t Number (to be filled in by Co.) <br />11>� <br />1400/ E Washington Ave 9 <br />P.O. Box 7162 <br />Madison, WI 53707-7162 <br />rl <br />CSOa��O9 <br />Sanitary Permit Application <br />State Number <br />`Transaction <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 />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />6294 Davis Drive <br />purposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel # <br />Maggie Diebel & David Songer <br />07-018-2-39-16-264 01-000-024000 <br />Property Owner's Mailing Address <br />Property Location <br />2034 Irene Street <br />Govt. Lot <br />NE'/., SE 1/4, Section 26 <br />City, State <br />Zip Code <br />Phone Number <br />Roseville, MN <br />7 <br />55113 <br />651488-1342 <br />(circle one) <br />T39N R16EorW <br />II. Type of Building (check all that apply) <br />Lot # <br />® 1 or 2 Family Dwelling - Number of Bedrooms <br />2 <br />Subdivision Name <br />❑ Public/Commercial - Describe Use <br />Block # <br />❑ City of <br />❑ State Owned - Describe Use <br />❑ Village of <br />CSM Number <br />Vol. 6 Pg. 160 <br />® Town of Meenon <br />III. Type <br />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 />IV. <br />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 <br />❑ 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 />300 <br />Rate(gpdsf) <br />VI. Tank Info <br />Capacity in <br />6 <br />GallonsTotal <br /># of Manufacturer <br />U <br />� p R <br />New Tanks Existing Tanks <br />Gallons Units <br />M c <br />p, U cin h <br />V) R Q <br />0 <br />Septic or Holding Tank <br />1200 <br />1200 1 Wieser <br />® ❑ <br />❑ ❑ <br />❑ <br />Dosing Chamber <br />800 <br />800 1 Wieser <br />® ❑ <br />❑ ❑ <br />❑ <br />VII. Responsibility Statement- I, the undersigned assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />er's S' aye' <br />MP/MPRS Number <br />Business Phone Number <br />Daniels Plumbing & Heating Inc <br />Pi Y <br />007086 <br />715-349-5533 <br />Plumber's Address (Street, City, State, Zip Code) <br />24056 State Rd 35/13.0. Box 326, Siren, WI 54872 <br />VIII. Coun /De artment Use Only <br />XApproved ❑ Disapproved Permit Fee Date Issued IsWing Agent Signature <br />p� <br />ElOwner Given Reason for Denial $ 3� Cly ` 0 <br />IX. Conditions of Approval/Reasons for Disapprpval <br />`b`b <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I I inches in size <br />SBD -6398 (R03/14) <br />