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`aVs:to County <br /> Industry Services Division Burnett <br /> P F'rT- 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> s P.O. Box 7162 An/ _AI_07/r <br /> Madison,WI 53707-7162 <br /> _at -to 376 <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,Stats. 26382 Lipsett Lake Rd <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Daniel Drescher 024311401100 <br /> Property Owner's Mailing Address Property Location <br /> 4325 Hanrehan Trl <br /> Govt.Lot 1 <br /> City,State Zip Code Phone Number SE'/4,NE'/4, Section 14 <br /> Savage,MN __[55378 (circle one) <br /> T39N ; R14EorW <br /> 11.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑ City of <br /> ❑State Owned-Describe Use ❑Number Village <br /> F3564 <br /> of <br /> 26 ® Town of Rusk <br /> I11.Type of Permit: Check only one box on line A. Complete line B if a licable <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 /> 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) 643 652 91-96 <br /> .7 <br /> VI.Tank Info Capacity in <br /> Gallons Total #of °= °v ; <br /> Manufacturer ro U <br /> Gallons Units ° o 2 2 <br /> New Tanks Existing Tanks a. U in v n w C7 Ll <br /> Septic or Holding Tank 1000 1000 1 Wieser ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> V11.Responsibility Statement- I,the undersigned,assume responsi ity for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signatu MP/MPRS Number Business Phone Number <br /> Dan Burch 253808 715.416.1642 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 1118N Front Street Spooner WI 54801 <br /> VIII.County/De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued �=nt Sign <br /> ❑ Owner Given Reason for Denial I $ 3 5. <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> Jxne <br /> JUL 2 7 2021 UD <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 size�j 00BurnettCWnaant <br /> SBD-6398(R03/14) '""� and Services Dep <br /> ��°t4uti <br />