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_,_ ""`�"'% Department of Safety County <br /> V's & Professional Services, BURNETT <br /> ,� ' ; j Sanitary Permit Number(to be filled in by Co.) <br /> � .,j Industry Services Division ��N 23_ .t 3 jo5���0� <br /> „„,.,,, Cs7-a3- 223 <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 <br /> purposes in accordance with the Privacy Law.s. 15.04(1)(m),Stats. 24293 NELSON ROAD <br /> I.Application Information—Please Print All Information j <br /> Property Owner's Name Parcel# <br /> i'axtD 9513 <br /> Caward 5ctct,s 07-014-2-38-15-07-1 03-000-011000 <br /> Property Owner's Mailing Address Property Location <br /> 1000-CANTON STREET. 2142`j 3 NQ,,Q,SDr1 kfi Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> Siirr �^Te `v T-- [AJQ S4-E-It,1 54022 r 3 715-279-2046 /+, /., Section 07 <br /> II.Type of Building(check all that apply) Lot# T 38 N R 15 WO <br /> EN or 2 Family Dwelling—Number of Bedrooms 2 NA Subdivision Name <br /> Block# NA <br /> ❑Public/Commercial—Describe Use <br /> NA ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> NA CXown of LAFOLLETTE <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. X New System Replacement System Other Modification to Existing System(explain) <br /> y p y ❑Additional Pretreatment Unit(explain) <br /> B. ❑ HoldingTank ❑ At-Grade M.../ Individual Site Design Other Type(explain) <br /> X in ground g <br /> (conventional) <br /> List Previous Permit Number and Date Issued <br /> C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner I <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(sf) l System tion <br /> 300 0.7 428.58 452 �95.41 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units o v <br /> New Tanks Existing Tanks v c 4Ui ` , R it 1 <br /> 0 <br /> aU in ti wC7 a <br /> Septic or Holding Tank <br /> 750 <br /> 750 1 WIESER X <br /> Dosing Chamber <br /> V.Responsibility Statement- I,the undersiaped,as/, responsibility for installation of the POWTS shown on the attached plans. <br /> F <br /> Plumber's Name(Print) P,timtir's S • .re MP/MPRS Number Business Phone Number <br /> CORY J. JACKSON i 824339 715-866-8944 <br /> Plumber's Address(Street,City,State,Zip Cod <br /> 24884 S.T.H. 35, SIREN, WI 54872 <br /> VI.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> Atkr Approved ❑Disapproved❑Owner Given Reason for Denial $ `v 2.5 I2b3/2 VZ3 f <br /> Conditions of Approval/Reasons for Disapproval <br /> Meer q,ll Sefback-5 ItLIZ6 r,Gt,ec k#-661 ) <br /> {o/low all tonal y at.� s -4e ✓eyuirel to <br /> 1l va'h•o� ,6.'11-P+ n4 us-f be ukcl f o have-- IrpEOJEIVED <br /> Sys-k-ry► e �6 <br /> "cv1 aU -1At l ii-k/19 -fite,-iv- DEC 1 1 2023 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inche <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R.03/22) <br /> REVISED <br />