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Department of Safety county BURNETT <br /> p & Professional Services, <br /> Sanitary Permit Number(to be filled in by Co.) <br /> Industry Services Division �4 -23 _ �'7 <br /> 4 _23-1 Zze l � $3� <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 PWTS-082301585-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),Stars. 27090 CONNERS BRIDGE RD <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> THOMAS J. & REBECCA L. O'BRIEN 07-018-2-39-16-02-2 04-000-011000 <br /> Property Owner's Mailing Address Property Location <br /> P.O. BOX 126 Govt.Lot NA l <br /> City,State Zip Code Phone Number <br /> WEBSTER, WI 54893 715-791-0600 SE �, NW y, section�? <br /> IL Type of Building(check all that apply) Lot# T 39 N R 16 vtW <br /> CN or 2 Family Dwelling-Number of Bedrooms 2 NA Subdivision Name <br /> Block# NA <br /> ❑Public/Commercial-Describe Use <br /> NA ❑City of <br /> ❑State Owned-Describe Use __— CSM Number ❑Village of _ <br /> NA [Rown of MEENON _ <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 P Y g Y (explain) (explain) <br /> ❑ New System Re lacement System El Modification to Existing System ❑ Additional Pretreatment Unit <br /> B. ❑ Holding Tank in ground ❑ At-Grade Mound ❑ Individual Site Design FO <br /> ther 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 NK I NV <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) I Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 2.0 150 195 101.70 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units U $ y y <br /> New Tanks Existing Tanks <br /> w U rn y in w C7 A, <br /> Septic or Holding Tank 840 840 1 WIESER (COMBOT X <br /> Dosing Chamber 500 500 <br /> V.Responsibility Statement- I,the undersigned,assume responsibili for in allation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sign a 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 /> Permit Fee Date Issued Vggent ign ture <br /> ,Approved ❑Disapproved $��� �� <br /> ❑Owner Given Reason for Denial ' ' <br /> Conditions of Approval/R ons f r Disapproval <br /> D <br /> � IEoVE <br /> AUU 0 3 2023 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 it I1 incth digerVlC@S Department <br /> SBD-6398(R.03/22) <br />