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Industry Services Division County <br /> 4822 Madison Yards Way BURNETT <br /> .,\$. Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> ,,,' <br /> S P.O.Box 7162 SON,aa -8,3 Madison,WI 53707-7162 c 31 9 _ b 1 04 314:7 o <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 NA <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 Services.Personal information you provide may be used for secondary (SAME) <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> DANIEL C. & LUCY A. KRIHA 07-018-2-39-16-26-4 02-000-027000 <br /> Property Owner's Mailing Address Property Location <br /> 6319 PIKE BEND ROAD Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> WEBSTER, WI 54893 NW /, SE '/, Section 26 <br /> II.Type of Building(check all that apply) Lot# T 39 N R 16 E or W <br /> Ell or 2 Family Dwelling-Number of Bedrooms 3 1 Subdivision Name <br /> Block# NA <br /> ❑Public/Commercial-Describe Use NA <br /> City of <br /> ❑State Owned-Describe Use CSM Number Village of <br /> V21 , P37 ❑✓ Town of MEENON <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if <br /> applicable.) <br /> A' ✓ ew System Replacement System Other Modification to ExistingSystem(explain) Additional Pretreatment Unit(explain) <br /> ❑N Y p Y ❑ Y ( p ) ❑ ( P ) <br /> B. ❑Bolding Tank EIn-Ground ❑At-Grade Mound ❑Individual Site Design Other Type(explain) <br /> (conventional) <br /> C. ❑Renewal Before ❑Revision Change of Plumber Dfransfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Appli ation Ratc(gpd/sf) Dispersal Area Required(st) bispersal Area Proposed(st) System Elevation <br /> 450 a,Q 225 227.50 91.22; 89.78 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units 0 o '9 <br /> 2 u <br /> New Tanks Existing Tanks ':'-1 c eJ u <br /> o <br /> av v� in iJ. C7 a- <br /> Septic or Holding Tank 1060 1060 1 INFILTRATOR I I I i ( ii Iry <br /> Dosing Chamber I I <br /> V.Responsibility Statement- I,the undersigned,assume respo ibi►ity for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb Sign, r MP/MPRS Number Business Phone Number <br /> CORY J. JACKSON „/ 824339 715-866-8944 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 9306 BLACK BROOK RD., WEBST R, WI 54893 <br /> VI.County/Department Use Only <br /> Srm Pe t Fee Date Issued [ss g Age Signatu <br /> Approved El Disapproved <br /> ❑Owner Given Reason for Denial 5/I?t v v r <br /> Conditions of Approval/Reasons for isappro al <br /> (eee- ag <br /> Attach to complete plans Tor the system and submit to the County only on paper not less than 8 1/2 x 11 I1 hes size 11 2022 lli4AY <br /> SBD-6398(R.03/21) Burnett County <br /> Land Services Department <br />