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Department of Safety cO°"ty <br /> BURNETT <br /> & Professional Services, <br /> E Ps -� Industry Services Division Sanitary Number(to filled;n by co.) <br /> RN , <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),Stats. 8601 OLSEN ROAD <br /> I.Application Information-Please Print All Information 2-7pot <br /> Property Owner's Name Parcel# <br /> KRYSTAL M. BURTON 7-016-2-39-17-12-2 03-000-013100 <br /> Property Owner's Mailing Address Property Location <br /> 5785 370TH STREET Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> NORTH BRANCH, MN 55056 651-235-1097 SW �<, NW v<, section I2 <br /> II.Type of Building(check all that apply) Lot# T 39 N R 17 ]� W <br /> EYJ or 2 Family Dwelling-Number of Bedrooms 3 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 /> V(23 P0117, mown of LINCOLN <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on tine B.Complete line C if <br /> applicable.) <br /> A. <br /> X New System Replacement System Other Modification to Existing System(explain) El Additional Pretreatment Unit(explain) <br /> B' ❑ Holding Tank X in ground ❑ At-Grade Individual Site Design Other Type(explain) <br /> GEOMAT <br /> C. ❑ Renewal Before ❑Revision ❑ Change of Plumber ❑Transfer to New Owner ist 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(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 2.00 225 227.50 96.25 FT. <br /> Capacity in Total #of Manufacturer <br /> a <br /> Gallons Gallons Units c <br /> Tank Information U .. N <br /> New Tanks Existing Tanks 2 c ai °o 4 <br /> a. U V) m in w C7 Gi <br /> Septic or Holding Tank 1000 --woo 1000 1 WIESER (COMBO) X <br /> Dosing Chamber 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 Signatur MP/MPRS Number Business Phone Number <br /> CORY J. JACKSON A824339 715-866-8944 <br /> Plumber's Address(Street,City,State,Zip Code) VW <br /> 24884 S.T.H. 35, SIREN, WI 54872 <br /> VI.County/Department Use Only <br /> Permit Fee Date Issued [ssuin Agent Signature <br /> Approved ❑Disapproved <br /> El $ 1 Owner Given Reason for Denial 26 <br /> Conditions of Approval/Reasons for Disapproval <br /> ft+ mi �Akr E (E C E RPE <br /> �D[[Dv,) a,U COLArif Y old 11W-e re <br /> K3M 09 2024 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x inches"erviees Department <br /> SBD-6398(R.03/22) <br /> ��25 dne�#�5t�13 <br />