Laserfiche WebLink
Department of Safety c°°°ty <br /> ;. BURNETT <br /> �i_ & Professional Services, Sanitary Permit Number(to be filled in by Co.) <br /> P Industry Services Division � _a3 — ?06 <br /> LOT 4 8q 2 <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),Slats. <br /> 3710 C.T.H. Q <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> MICHAEL & JULIE SCHARPING 7-012-2-40-15-24-5 05-006-014200 <br /> Property Owner's Mailing Address Property Location -.4 <br /> 305 W SHAMROCK DRIVE Govt.Lot 6 cJ1�7v <br /> City,State Zip Code Phone Number <br /> ARLINGTON, MN 55307 'So-1-3\`1-al0y 1 SW i -'i°, section 24 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 15 `l Xw <br /> EX or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name <br /> Block# NA <br /> ❑Public/Commercial-Describe Use <br /> NA ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 4769;V26,P252 Efown of JACKSON _ <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement'andr applicable on line A. Check one box on line B.Complete line C if <br /> applicable.) <br /> A. <br /> New System Replacement System XOther Modification to Existing System(explain) El Additional Pretreatment Unit(explain) <br /> ADD NEW TANK <br /> El Holding Tank X in ground El At-Grade Individual Site Design Other <br /> B. <br /> d her Type(explain) <br /> (conventional) ad filter <br /> L <br /> ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner ist Previous Permit Number and Date Issued <br /> Expiration 221991/07-20- 1994 <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 0.7 642.86 720 94.68 FT. <br /> Capacity in Total #of Manufacturer v <br /> Tank Information Gallons Gallons Units o D <br /> New Tanks Existing Tanks v <br /> a U in 1n L5 i,. 0 a <br /> Septic or Holding Tank 840 1000 1840 1 WIESER(COMBO) X <br /> Dosing Chamber 500 500 <br /> V.Responsibility Statement—I,the undersigned,assume responsibility fo installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signatur MP/MPRS Number Business Phone Number <br /> CORY J. JACKSON 824339 715-866-8944 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 24884 S.T.H. 35, SIREN, WI 54872 <br /> �V,(I.County/Department Use Only <br /> IXJ Approved ❑Disapproved Permit Fee� Date Issue Issuing gent Signature <br /> ❑Owner Given Reason for Denial $ v 1 12_2 2023 <br /> Conditions of Approval/Re <br /> asons for Disapproval C( *3 <br /> E <br /> SEP 2 12023 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1 inches in s' urnett County <br /> 17 Land Services Department <br /> SBD-6398(R.03/22) <br />