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,t Industry Services Division County <br /> ' 4822 Madison Yards Way BURNETT <br /> ,, Madison,WI 53705 Sanitary Permit Number(to be filled in by Coo.) <br /> ;, PS ,' P.O.Box 7162 91)Q--32—c9,7 643`'l13 <br /> Madison,WI 53707 7162 /�-)t Ir, <br /> "spy...\l. Ct� ''p�o2 `.�C. <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 25585 SAND RIDGE TRAIL <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I.Application Information-Please Print All Information 4 35 6 4 <br /> Property Owner's Name Parcel# <br /> RONALD J. & SANDRA M. BODICK 07-040-2-39-19-27-2 02-000-011700 <br /> Property Owner's Mailing Address Property Location <br /> 514 AM E R I CAS WAY #11924 Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> BOX ELDER, SD 57719 612-363-4140 NW 'A NW 'A, Section 27 <br /> II.Type of Building(check all that apply) Lot# T 39 N R 19 E or W <br /> 0lor2 Family Dwelling—Number ofBedrooms 2 7 <br /> Subdivision Name <br /> Block# NA <br /> [Public/Commercial—Describe Use NA <br /> City of <br /> ❑State Owned—Describe Use CSM Number Village of <br /> #5024, V28, P166 OTown of WEST MARSHLAND <br /> HI.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. ✓ New System De placement System ther Modification to ExistingSystem(explain) Additional Pretreatment Unit(explain) <br /> ❑ Y ❑ p Y Y ( P ) ❑ ( P ) <br /> B. Holding Tank El In-GroundElAt-Grade ❑Mound ❑Individual Site Design Other Type(explain) <br /> (conventional) <br /> C. ElRenewal Before El Revision Change of Plumber ❑I'ransfer 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 Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 300 0.7 428.18 450 96.80 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units aZ l t 'a <br /> New Tanks Existing Tanks L o 9 y 1 <br /> yb o (0p d a U n ti n a c7 w <br /> Septic or Holding Tank 75D- *56- 1 WIESER V I I I <br /> Dosing Chamber I I ❑ ❑ ❑ <br /> V.Responsibility Statement- I,the undersigned,assume res on 'bility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Pl er's Si e 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., WEBSTER, WI 54893 <br /> VI.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee v,v Date Issued Is in Agent gnature <br /> ❑Owner Given Reason for Denial 8 426 -- 3/Pq/�a <br /> Conditions of Approval/Reasons for Disapproval <br /> tsDco;t ‘-c.,e b 'ro be, 5c ' ,i'cofn rav, ascb\e. hor,� of wa�cri tank _ I 1 <br /> )SAS-crY\ E\c40„-Von mos.Y be / 6. g w1 \2" o'f so,\ Cover `t , i-i7 >'-t <br /> D ECIEUVIE• <br /> MAR 2 3 ?02? I <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 icch in size <br /> SBD-6398(R.03/21) - Burnett County <br /> Land Services Department <br />