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r x County <br /> el Industry Services Division BURNETT <br /> tisr, <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> $ P.O. Bx 7162 5 A,N-a 0` 1 19Tk Madison,WI 53707-7162 <br /> s. <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 03116 <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. 26586 BREDE LANE <br /> L Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> STEPHAN&KATHY METCALF 07-024-2-39-14-12-5 05-001-01160 <br /> I!53'81 <br /> Property Owner's Mailing Address Property Location <br /> 331 SOO LINE RD <br /> Govt.Lot 1 <br /> City,State Zip Code Phone Number '/a, 1/., Section 12 <br /> HUDSON,WI 54016 651 269 7169 (circle one) <br /> T39N ; R14WEorW <br /> IL Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> ❑Public/Commercial—Describe Use Block# <br /> 0 City of <br /> ❑State Owned—Describe Use <br /> 0 Village of <br /> CSM Number <br /> 4390 V24 P24 ® Town of RUSK <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ® New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner soil test filed 9/2014 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ® Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 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) 643 650 >=90.6'<91.6' <br /> .7 <br /> VI.Tank Info Capacity in <br /> Gallons Total #of Manufacturer al c' h. y . <br /> Gallons Units 2 o i .g d ao <br /> .11 41 <br /> New Tanks Existing Tanks , U rn ,e rn u. 0 P. <br /> Septic or Holding Tank 700/300 1000 1 SKAW PARTITIONED ® 0 0 0 0 <br /> Dosing Chamber 0 0 0 0 0 <br /> VII.Responsibility Statement-I,the undersigned,assume ponsibility for if tion of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) <br /> M&v SEPTIC & E 4 i lure MP/MPRS Number Business Phone Number <br /> Mel Ferguson dba _R TMINE ROAD - ! MPRS 224879 <br /> Plumber's Address(Str � , , liI "I 54801 , <br /> 715--6'1I13511Y111-YY17482 <br /> �VIII_I County/Department Use Only <br /> /JQ Approved 0 Disapproved Permit F do ssu ssuin Agent Si e / i / <br /> v <br /> 0 Owner Given Reason for Denial $NA 2 '02.0 / — <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 9/ kiitsfiK Brit Wad' be used. E C E 0 d E <br /> Wcl( t be 5o0 lbw► 1>rwi•, itl4. , i <br /> Citi*c(et 1 ws+ lx. 51f+ glum Nlt l��s lwe�t. JUN 1 8 2020 <br /> Attach to complete plans for the system an submit to the County only on paper not less than 8 1/2 a 11 inch 1 n 1 <br /> Burnett County <br /> Land Services Department <br /> I.„ 4511 IC <br />