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5—1 I—A-01 <br /> v7t fir` County <br /> Industry Services Division Burnett <br /> " ,M 1400 E Washington Ave <br /> P.O.Box 7162 Sanitary Permit Number(to be filled in by Co. <br /> Madison,WI 53707-7162 $"y� <br /> csutv�f <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 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 Stars. 6425 Linda Lane,Danbury,WI 54830 <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# i3a�8.Z <br /> Terry Wier 07-020-240-16-14-5 05-005-022000 <br /> Property Owner's Mailing Address Property Location <br /> 14915 Gleason Lake Drive <br /> Govt.Lot 5 <br /> City,State Zip Code Phone Number '/., '/<, Section 14 <br /> Plymouth,MN 55447 952454-2899 (circle one) <br /> T40N R16EorW <br /> II.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms 13 Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑State Owned-Describe Use [I City of <br /> CSM Number ❑ Village of <br /> Vol.8 Pg. 178 ® Town of Oakland <br /> III.Type of Permit: Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System ❑ Replacement System ®Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Pemmt Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber 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.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) <br /> VI.Tank Info Capacity in <br /> a <br /> Gallons Total #of Manufacturer U <br /> Gallons Units o o e <br /> New Tanks Existing Tanks a U in v w 0 P. <br /> Septic or Holding Tank 1000 1000 1 Wieser ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber I I I I 1 ❑ 1 ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigne assume responsibi' for instal on of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) P er's gna MP/MPRS Number Business Phone Number <br /> Daniels Plumbing&HeatingInc ` 007086 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7660 Anderson Street/P.O.Box 326,Siren,WI 54872 <br /> VIII.Count [Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing gent Si lure <br /> -L_ <br /> El Owner Given Reason for Denial $ -37 f 3 X/Z' 9 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> APPROno MAY 17 2019 <br /> BURNETTCOUNTY <br /> Attach to complete plans for the rem and su�bm�it�to t a ly on paper not less than 8 1/2 x I I inOONNG <br /> SBD-6398(R03/14) <br />