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,�\� Industry Services Division County <br /> "1 ��'t\ 4822 Madison Yards Way Burnett <br /> _ Madison,WI 53705 Sanitary ( y <br /> Sanita Permit Number to be filled in b <br /> P.O.Box 7302 Co.) <br /> Madison,WI 5302 <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 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),Slats. 26276 W LIPSETT LAKE RD <br /> I.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> ROBERT M&DIANE M MARGO 07-024-2-39-14-14-5 05-001-019000 <br /> Property Owne8500 FRANLO RD UNIT 201r's Mailing Address Property Location <br /> Govt.Lot 1 <br /> City,State Zip Co55344de Phone Number <br /> EDEN PRAIRIE MN 651492-5637 /4, /4, Section 14 <br /> II.Type of Building(check all that apply) Lot# T 39 N R 14 W <br /> ❑x 1 or 2 Family Dwelling—Number of Bedrooms 2 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 Rusk <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 /> ❑ New xReplacement System El Other Modification to Existing System(explain) El Additional Pretreatment Unit(explain) <br /> System <br /> B. X❑ Holding In-Ground ❑ At-Grade Mound ❑ Individual ❑ Other Type(explain) <br /> (conventional) <br /> Tank Site Design <br /> C. ❑ Renewal ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner List Previous Permit Number and Date <br /> Before Issued 13-71 O <br /> Ex iration <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area System Elevation <br /> Zcc Proposed(sf) <br /> Capacity Total #of Manufacture <br /> Tank Information in Gallons Units <br /> Gallons J U° <br /> New Exisfing Tanks v 15 <br /> N 0 <br /> Tanks a n ti n C7 p <br /> Septic or Holding Tank x 3000 1 Wieser <br /> Dosing Chamber <br /> V.Responsibility Statement- I,the undersigned,assu a responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber 'ature MP/MPRS Business Phone Number <br /> Luke Schmitz Number 715-520-2434 <br /> 894121 <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 /> 3�5 Ins❑Owner Given Reason <br /> for Denial V <br /> D E G(� IE <br /> rol�ow ctu. �„�►� c� S�� � AUG o 4 2023 <br /> Burnett County <br /> Land Services Department <br />