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� �"RraT Department of Safety cO11'ry BURNETT <br /> £, & Professional Services, Sanitary Permit Number(to be filled in by Co.) <br /> Industry Services Division S.N gL+—C�on <br /> .,� 4— cam?vim' <br /> Sanitary Permit Application State Transaction N tuber <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 <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. <br /> I.Application Information=Please Print All Information 8608 S. SHORE DRIVE <br /> Property Owner's Name Parcel# <br /> BENJAMIN& CRYSTAL JACOBS 7-036-2-40-17-23-5 15-048-013000 <br /> Property Owner's Mailing Address Property Location <br /> P.O. BOX 247 Govt.Lot NA TAX ID: 25380 <br /> City,State Zip Code Phone Number <br /> SPOONER, WI 54801 '/<, '/., Section 23 <br /> 11.Type of Building(check all that apply) Lot# T 40 N R 17 4Xw <br /> IN or 2 Family Dwelling-Number of Bedrooms 4 3 Subdivision Name <br /> Block# I BASS LAKE SHORES <br /> ❑Public/Commercial-Describe Use <br /> NA ❑city of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> NA ikown of UNION <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 /> New System X Replacement SystemT Additional Pretreatment Unit(explain) <br /> Other Modification to Existing System(explain) <br /> B. HoldingTank x ❑ At-Grade 9�G../ Individual Site Design Other <br /> m ground GEOMAT � <br /> (conventional) <br /> List Previous Permit Number and Date Issued <br /> C• ❑ Renewal Before ❑ Revision Change of Plumber Transfer to New Owner 311039/03-02-1998 2 1 go <br /> Expiration <br /> IV.Dispersal/I'reatmeni Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed System Elevation <br /> 600 0 300 302.25 98.00 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units t? •8 h 2 <br /> New Tanks Existing Tanks c n e c"a <br /> a V m y inn w C7 Gi. <br /> Septic or Holding Tank 1200 1200 1 WIESER (COMBO) X <br /> Dosing Chamber 800 800 <br /> V.Responsibility Statement-I,the undersigned,assume respon ' ility r instyllation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signa 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 Pe(nnnit Fee Date Issued Issuing Agent Sign at re <br /> ❑Owner Given Reason for Denial $ 1 �' Z�Z <br /> Conditions of Approval/Reasons for Disapproval <br /> l to w alb -I-e re Y �5 E(10�11 F 0 Y IE <br /> EX iS7k n <br /> I i S I <br /> Attach to complete plans for the system and submit to the County only on paper not less than S in x Ili hes Id"ize <br /> Burnett County <br /> SBD-6398(R.03/22) Land Services Department <br />