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""""` Department of Safety County <br /> Burnett <br /> >. 1 - &Professional Services, <br /> s .. $ = itary Pe Number(to be filled in by Co.) <br /> P: Industry Services Division — l�'.23 <br /> CRY--22— /g ' <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 Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. 26602 Loffgreen Rd. <br /> I.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> Gwynn Anderson 02411006200 <br /> Property Owner's Mailing Address Property Location 4- I5Isti <br /> 101 Park Ave. <br /> Govt.Lot 6 <br /> City,State Zip Code Phone Number <br /> Luck WI 54853 / /<, Section 10 <br /> II.Type of Building(check all that apply) Lot# T 39 N R 14 E or W <br /> , 1 or 2 Family Dwelling—Number of Bedrooms 3 4 Subdivision Name <br /> Block# <br /> 0 Public/Commercial—Describe Use <br /> 0 City of <br /> 0 State Owned—Describe Use CSM Number 0 Village of <br /> Town of Rusk <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. ❑New System WReplacement y ,�/ System ❑ Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) <br /> B. ❑ Holding Tank I�In-Ground ❑At-Grade ❑Mound ❑ Individual Site Design ❑Other Type(explain) <br /> / (conventional) <br /> C. ❑Renewal Before ❑Revision ❑ Change of Plumber ❑ Transfer 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 /> 450 5 900 932 95.5 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units m v 0 <br /> New Tanks Existing Tanks g c 2. 3 Y 13 g <br /> a, U rn y rn w C7 a. <br /> Septic or Holding Tank 1000 1000 1 Wieser X <br /> Dosing Chamber 600 600 1 Wieser X <br /> V.Responsibility Statement-I,the undersigned,assume responsibility for i tallation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si e � MP/MPRS Number Business Phone Number <br /> Rick Brown . 231251 715-419-0739 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 637 Spooner WI 54868 <br /> VI.County/Department Use Only <br /> <Approved 0 Disapproved Permit Fee Date Issued uI g ent Signa Ai <br /> ❑Owner Given Reason for Denial $14 5� L 013( p�'y) �I6(J <br /> Conditions of Approval/Reasons or Disapp val <br /> + meet all 5e b u-5 .d . <br /> 4 cysiyi ill 05e,1 be 1„A.e.4 , <br /> ECEilVE,D <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/2 x tdin in sap 2 9 ton ` <br /> SBD-6398(R.03/22) A <br /> Burnett County <br /> Land Services Department <br />