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/f-'`�"+,F Industry Services Division County <br /> 4822 Madison Yards Way Burnett <br /> Madison,WI 53705 Sanitary Permit Number(to be filled in by <br /> j P.O.Box 7302 Co.) / ,L <br /> �X <br /> Madison,W1 5302 2? z bV I <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.2](2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is <br /> required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to the Project Address(if different than mailing <br /> Department of Safety and Professional Services.Personal information you provide may be used for secondary address) <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. 1890 DUBOIS RD <br /> I.Application Information—Please Print All Information y ; <br /> Property Owner's Name Parcel# <br /> TINDELL LAKE CABIN LLC 7-028-2-40-14-34-5 05-002-024000 <br /> Property Owner's Mailing Address Property Location <br /> 8337 79TH ST S <br /> Govt.Lot 2 <br /> City,State Zip Code Phone Number <br /> COTTAGE GROVE MN 55016 /,, /4, Section 34 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 14 W <br /> ❑x 1 or 2 Family Dwelling—Number of Camper Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> x❑Town of Scott <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 <br /> if applicable.) <br /> A. <br /> ❑X New Replacement System ❑ Other Modification to Existing System(explain) El Additional Pretreatment Unit(explain) <br /> System <br /> B. �X In-Ground(conventional) El At-GradeMound ❑ Individual ElOther Type(explain) <br /> Holding an Site Design <br /> C. El Renewal El Revision El Change of Plumber ❑ List Previous Permit Number and DateTransfer to New Owner Issued <br /> Before <br /> Expiration <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/st) Dispersal Area Required(sf) Dispersal Area System Elevation <br /> oO Proposed(sf) <br /> Capacity Total #of Manufacture <br /> Tank Information in Gallons Units = <br /> Gallons j <br /> New Existing Tanks Y y <br /> Tanks a` n H i C7 0. <br /> Septic or Holding Tank x 000 1 Wieser <br /> Dosing Chamber <br /> V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's re MP/MPRS Business Phone Number <br /> Luke Schmitz Number 715-520-2434 <br /> 884121 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Po Box 160 Shell Lake WI 54871 <br /> VI.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ElOwner Given Reason $375 IE� F /]� �C 2 <br /> for Denial (� \Vf <br /> CON 'f't t�NS • <br /> 0 n � au� �e.-Iloa S - 0 <br /> NOV 2 2 2023 <br /> R.U. oj_,� Cowa+y oi-xA S-ta-Ac Burnett County <br /> +D-r"k 40 6e- Se.rViCkJ IrO6� -LKId OX Land Services De artment <br /> J ,,075*0 Gamut*3i % <br />