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Department of Safety county <br /> BURNETT <br /> & Professional Services, <br /> Sanitary Permit Number(to be filled in by Co.) <br /> Industry Services Division P4,J�_ (P 5-�'r (vSLfS(o <br /> 9 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 POWTS-072301405-C <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. SAME <br /> I.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> SCOTT K. & TARA L. GRAMS 7-034-2-37-18-21-5 05-003-023000 <br /> Property Owner's Mailing Address Property Location <br /> 20932 LAKEWOOD DRIVE Govt.Lot 3&4 <br /> City,State Zip Code Phone Number <br /> GRANTSBURG, WI 54840 651-357-5409 �i,, Section 21 <br /> II.Type of Building(check all that apply) Lot# T 37 N R 18 T-4 W <br /> IN or 2 Family Dwelling—Number of Bedrooms 2 1 Subdivision Name <br /> Block# NA <br /> ❑Public/Commercial—Describe Use <br /> NA ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> V3,P190 [kown of TRADE LAKE <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. Y X P Y g Y (explain) (explain) <br /> New S stem Replacement System Other Modification to Existing SystemAdditional Pretreatment Unit <br /> B. <br /> ❑ Holding Tank in ground ❑ At-Grade ,Y !JlS.,✓ Individual Site Design Other Type(explain) <br /> (conventional) I add filter <br /> C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑Transfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration f 0er 3(1 3 <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) System Elevation <br /> 300 2.0 150 195 97.85 FT. <br /> Capacity in Total #of Manufacturer :: <br /> Tank Information Gallons Gallons Units p c '$ 2 <br /> New Tanks Existing Tanks U <br /> u G Y y v y <br /> a` U i7 12vl7 ti w C7 CL <br /> Septic or Holding Tank ,,,2000 ZtOO 2000 1 S X <br /> Dosing Chamber 750 750 1 WIESER X <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 Sign atu 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 /> VI.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee ee Date Issued <br /> 2 Issuin Age Sign <br /> $ a e <br /> ❑Owner Given Reason for Denial �� �/ �a3 <br /> Conditions of Approval/Reasonp for Pisapproval <br /> IV IE <br /> D I 'll 1 1 2123 <br /> . 0 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I I inches in sflrnett County <br /> Land Services De artment <br /> tea... <br /> SBD-6398(R.03/22) <br />