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! County <br /> Industry Services Division Burnett <br /> 1400 E Washington Ave Sanitary Permit Number(to be file in by Co.) <br /> .° t-�( P.O. Box7162 di� �� <br /> Madison,WI 53707-7162 <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 Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary 1345 Racine Dr. <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Slats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# 3 S7 <br /> Joseph Gallus 070282401413515432039000 <br /> Property Owner's Mailing Address Property Location <br /> 3832 Turtle Rd. Govt.Lot 4 <br /> City,State Zip Code Phone Number y4, %4, Section 13 <br /> Minnetrista MN 55375 (circle one) <br /> T 40 N, R 14 E or W <br /> 11.Type of Building(check all that apply) Lot# <br /> Q 1 or 2 Family Dwelling-Number of Bedrooms 3 1 Subdivision Name <br /> Block# <br /> i <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Q Town of Scott <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. a0 New System ❑ Replacement System <br /> y p y ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that aPE1 <br /> Q 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.Dis ersallTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 1.7 1643 650 95.4 <br /> Vl.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units v$ F N <br /> New Tanks Existing Tanks c v Y 2 _zi <br /> a U v u C7 a <br /> Septic or Holding Tank 1000 1000 1 Wieser X <br /> I Losing Chamber <br /> VI1.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sign agre/ MP/MPRS Number Business Phone Number <br /> Rick Brown 231251 715-419-0739 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 637 Spooner WI 54801 <br /> V111.Coon /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee_ Date Issued y Issuing Agept Signature <br /> El Owner Given Reason for Denial $ _3`7_ •' <br /> IX.Con it' s r PRUV for Disapproval <br /> IHI MAY 2 8 2019 Oil <br /> Attach to complete plans for the m and submit to the Cou aper not less than 8 1/2 11 inc <br /> sllrnettCounty <br /> Land Serv(cas Department _j <br /> SBD-6398(R0313) /�, G � 5 at- ���� <br />