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c,otrxnraE,To County <br /> < Industry Services Division Bumett <br /> xj 1400 E Washington Ave <br /> ° SanitaryPermit umber(to be filled in by Co.)P.O. Box 7162 5A - j <br /> ` _ r Madison,WI 53707-7162 5y 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. 10639 SILVER LAKE RD GRANTSBURG 54840 <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> KF.VIN&KATERINA STROM 07-042-2-38-18-36-5 05-002-021000 <br /> Property Owner's Mailing Address Property Location <br /> 9411 BRIAR CIRCLE <br /> Govt.Lot 2 <br /> City,State Zip Code Phone Number %4, /4, Section 36 <br /> BLOOMINGTON,MN 55437 652-8314551 (circle one) <br /> T38N; Rl8WEorW <br /> 11.Type of Building(check all that apply) Lot# <br /> Z 1 or 2 Family Dwelling-Number of Bedrooms I Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑State Owned-Describe Use ❑ City of <br /> rCSMcssilly, <br /> Number ElVillage of <br /> V21 P09(#374180) ® Town of WOOD RIVER <br /> Ill.Type of Permit: Check only one box on line A. Complete line B if applicable) <br /> A. Z New System ❑ Replacement System ❑ Trearment/Holdin Re g Tank Replacement Only El 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 /> IV.Type of POWTS S stem/Com onent/Device: (Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil N 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(grill Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 300 Rate(gpdsf) 300 300.3 q <br /> 1.0 5 <br /> VI.Tank Info Capacity in <br /> Gallons Total #of Manufacturer R E <br /> Gallons Units <br /> c g pp a <br /> New Tanks Existing Tanks 2 <br /> Septic or Holding Tank 840 840 1 WIESER CONCRETE INC. ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber 500 500 1 WIESER CONCRETE INC. Z ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for ins ation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si re MP/MPRS Number Business Phone Number <br /> BRENT LUEDTKE I 980108 651-336-2167 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 162 BRIDGE WATER TRAIL HUDSON,WI 54016 <br /> VIII.Coun /De artment Use Onl <br /> Approved ❑ Disapproved Permit Fee` O rJ Date Issuqed -7 Issuing Agent Signatur <br /> ❑ Owner Given Reason for Denial $ 7^y ' Z�pr ' / <br /> IX.Conditions of Approval/Reasons for Disapproval Rh� <br /> ECE9p QE ID <br /> JUN 10 2017 <br /> Attach to complete plans for the system and submit to the County only on papernot lessthan 8 1/2 x 11 size <br /> BURNETT COUNTY <br /> ZONING <br /> SBD-6398(R03/14) <br />