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VrrARTA,p�,l Industry Services Division County <br /> 4822 Madison Yards Way Burnett <br /> Madison,WI 53705 Sanitary=ermit Number(to be filled in by Co.) <br /> �*>" <br /> P.O.Box 7302 � 2.3 -183 I �q0y�9 <br /> Madison,WI 53707 10`> <br /> .r1;11roxnL'�p <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 27980 N POINT LAKE RD <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> 1.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> MARCIA LAGRANDER 07-012-2-40-15-28-2 02-000-016000 <br /> Property Owner's Mailing Address Property Location <br /> 4044 LONGFELLOW AVE Govt.Lot <br /> City,State Zip Code Phone Number <br /> MINNEAPOLIS, MN IS6H p1 v4, Section 28 <br /> II.Type of Building(check all that apply) Lot# t T 40 N R 15 E o <br /> z1 or 2 Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> City of <br /> State Owned—Describe Use CSM Number Elvillage of <br /> Olct� Town of Jackson <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. R]New System []Replacement System Other Modification to Existing System(explain) DAdditional Pretreatment Unit(explain) <br /> B' ❑FIolding Tank zIn-Ground E]At-Grade Mound ❑Individual Site Design Other Type(explain) <br /> (conventional) <br /> C. Renewal Before Revision ❑Change of Plumber Transfer to New O,,imer ist Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dispersat/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(so Dispersal Area Proposed(sf) System Elevation <br /> 450 0.7 1643 1646 193.00 <br /> Capacity in Total #of Manufacturer Y <br /> Tank Information Gallons Gallons Units o <br /> C U r, U N <br /> New Tanks Existing Tanks 4 c Y <br /> a U v y y a C7 0 <br /> Septic or Holding Tank 1000 1000 1 WIESER CONCRETE ✓ <br /> Dosing Chamber <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) Plumbe' ignature MP/MPRS Number Business Phone Number <br /> Travis Butterfield 652879 715-634-8176 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 14346W St. Rd. 77, Hayward, WI 54843 <br /> VI.County/Department Use Only <br /> Approved ❑Disapproved $ermit�1a5 D Wj�gent S' t <br /> ❑Owner Given Reason for Denial J <br /> Conditions of Approval/Reasons for Disapproval <br /> f y►ee.�- all Co. � 5� 'rr✓,��5 � C� [� 0�[� <br /> P 0 5 2023 <br /> Burnett Count <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1 inchek"roervices Department <br /> SBD-6398(R.02/22) <br /> 376" sTb <br /> auo 0 4)X I eje may <br />