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.utpMt.T4 Department of Safety County <br /> BURNETT <br /> & Professional Services, Sanitary Pe it Number(to be filled in by Co.) <br /> Industry Services Division <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 /> I.Application Information-Please Print All Information, 4465 DEERPATH TRAIL <br /> Property Owner's Name Parcel# -T4X`D U%2 S <br /> TIMBERLAND COTTAGES 7-012-2-40-15-10-5 15-128-142000 <br /> Property Owner's Mailing Address Property Location <br /> 19200 CO.RD.40 Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> BELLLE PLAIN, MN 56011 /<, `A, Section 10 <br /> IL Type of Building(check all that apply) Lot# T 40 N R 15 <br /> EYJ or 2 Family Dwelling-Number of Bedrooms 3 133 Subdivision Name b v, 8 40 <br /> Block# VOYAGER VILLAGE <br /> ❑Public/Commercial-Describe Use <br /> NA ❑city of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> NA IXown 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. <br /> X New System Replacement System Other Modification to Existing System(explain) 11 Additional Pretreatment Unit(explain) <br /> B. ❑ Holding Tank X in ground GEOMAT ❑ At-Grade la'—a/ Individual Site Design Other Type(explain) <br /> (conventional) <br /> C• ❑ Renewal Before ❑ Revision ❑Change of Plumber ❑ Transfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dispersal/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 /> Q <br /> 450 0.7 642.86 652 <br /> Capacity in Total #of Manufacturer « <br /> Tank Information Gallons Gallons Units a ;; 0 <br /> New Tanks Existing Tanks <br /> 0 <br /> a V iin y rn w C7 0, <br /> Septic or Holding Tank 1000 1000 1000 1 WIESER COMBO X <br /> Dosing Chamber 650 650 650 <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 Signature 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 Dat Iss ed/�[J [ssuin Agent Signature <br /> ❑Owner Given Reason for Denial 26`0 �� <br /> Conditions of Approval/Reasons for Disapproval �] <br /> sfe au se4uds r <br /> v <br /> re i/' �ze�?il , <br /> Follow a,u courrf y a S �cc e L4D be `6. 5 / S��n GVvrksh�t°�- <br /> ounty <br /> I and De artment <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1 Anchn <br /> ��25 c/44 <br /> SBD-6398(R.03/22) <br />