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4,� ttp County <br /> Industry Services Division MMPUTERISCANNED <br /> 3 S 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P P.O. Box 7162 <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04 i m,Stats. 1119 COUNTY RD E <br /> L Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> TODD&MICHELE MUELLER 07-028-2-40-14-24-5 05-005-025000 <br /> TAX#18500 <br /> Property Owner's Mailing Address Property Location <br /> 1429 LAMETTI LANE <br /> Govt.Lot 4&5 <br /> City,State Zip Code Phone Number 1/4, 1,/4, Section 36 <br /> AR.DEN HILLS,MN 55112 651 295 6791 (circle one) <br /> T39N R11EorW <br /> It Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> ❑ Public/Commercial-Describe Use Block# <br /> ❑ City of <br /> ❑ State Owned-Describe Use El Village of <br /> CSM Number <br /> V6 P 20 1.55 ACRES ® Town of SCOTT <br /> M. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System ❑ Replacement System ® Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner 31437(10425)10-6-1982 R HOPKINS <br /> IV. Type of POWTS System/Component/De-vice: (Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ®Other Dispersal Component(explain) TANK ONLY TO EXISTING DRAINFIELD ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 Rate(gpdsf) 18X 36 648 S FT 648 EXISTING @ 92.52' <br /> RATE 4MIN INCH <br /> VL Tank Info Capacity in <br /> Gallons Total #of n <br /> Gallons Units Manufacturer c a <br /> New Tanks Existing Tanks P U �z n 'X C) P. <br /> Septic or Holding Tank 700-300 1033 SKAW PARTITIONED ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for install '14 of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si ature MP/MPRS Number Business Phone Number <br /> Mel Ferguson dba M&K SEPTIC & E CAVATI01� PRS 224879 <br /> Plumber's Address(Str <br /> SPOONER,WI 54801 <br /> VIII. Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee O Date Issued Issuing Agent Signa re <br /> El Owner Given Reason for Denial $ 3 /S /, 3 0 <br /> IX.Conditions of ApprovaUReasons for Disapproval ECEWE <br /> JUL 3 0 2015 FA <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 in s i 'ze <br /> BURNETT COUNTY <br /> -� ZONING, <br />