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�aTtr- <br /> o� kxr County <br /> Industry Services Division Burnett <br /> $ 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> i P$ P.O. Box 7162 ��/ <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 <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. 28294 Johnson Lake Rd. <br /> I. Application Information—Please Print All Information RVAI <br /> Property Owner's Name Parcel# <br /> Laura Reynolds 07-020-2-40-16-11-4 01-000-013000 <br /> Property Owner's Mailing Address Property Location <br /> 1131 Farrington Street <br /> Govt.Lot <br /> City,State Zip Code Phone Number NE 1/4,SE 1/4, Section 11 <br /> St.Paul,MN 55117 circle one) <br /> T40N R16Eo <br /> H.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling—Number of Bedrooms Na Subdivision Name <br /> NA <br /> ❑Public/Commercial—Describe Use Block# <br /> El City of <br /> ❑State Owned—Describe Use <br /> CSMNumber ❑ Village of <br /> Na ® 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. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> 1V.Type ofPOWTS 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) 750 750 Eisa C-1=105.00 C-2=104.00' <br /> .60 <br /> VI.Tank Info Capacity in <br /> c <br /> p v <br /> Gallons oGallo s UnitsManufacturer w d <br /> New Tanks Existing Tanks w 0 rn va w C7 a <br /> Septic or Holding Tank 1000 1000 1 Wieser Concrete ® 0 ❑ ❑ ❑ <br /> Dosing Chamber 600 600 Combination ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the andersignedlmsuing responsibility for ussuillation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) P 's MPAVRS Number Business Phone Number <br /> Dayton Daniels 007086 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> P.O.Box 326 Siren WI 54872 <br /> VIII,County/Department Use Only <br /> Approved I ❑ DisapprovedPermit Fee O p Date Issued Issuing Agent Signature <br /> lOwner Given Reason for Denial $ 3 7:57 j/fLaz <br /> UL Conditions of Approval/Reasons for Disapproval EC EU E <br /> Rn <br /> MAY 112016 <br /> Attach to complete plans for the system and submit to the County only an paper not leas than 812 s r ' sill <br /> BURNETT COUNTY <br /> ZONING <br />