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County <br /> Industry Services Division Burnett <br /> X ; 0 1400 E Washington Ave <br /> $ $ K I Sanitary Permit Number(to be filled in by Co.) <br /> F S P.O. Box 7162 r <br /> Madison,WI 53707-7162 <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 <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(1)(m),Stars. 1130 ROBERTS RD <br /> 1. Application Information-Please Print All information <br /> Property Owner's Name Parcel# <br /> DOUGLAS&PAMELA LUNDELL 07-028-240-14-24-5 05-005-015000 <br /> Property Owner's Mailing Address Property Location <br /> 4215 EVERGREEN LN N <br /> Govt.Lot 5 <br /> '/., y., Section 24 <br /> City,State Zip Code Phone Number (circle one) <br /> PLYMOUTH,MN 55441 T 40 N14; R W E or W <br /> 11.Type of Building(check all that apply) l.ot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms _ 27 Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> [:1 City of <br /> ElState Owned-Describe Use <br /> CSM Number ❑ Village of <br /> ® Town of Scott <br /> 111.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 <br /> IV.Type of POWTS System/Component/Device: 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) ❑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) 642 652 94-91 <br /> VI.Tank info Capacity in <br /> c <br /> Gallons Total #of o 07 <br /> Manufacturer fach <br /> Gallons Units G t 2 0 <br /> New'1'anks Existing Tanks 2 U v Jv Z U C. <br /> Septic or Holding Tank x 1000 1 Wieser ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber x 600 1 Wieser ® ❑ ❑ ❑ ❑ <br /> Vll.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's S)'gtature s-- -� MP/MPRS Number Business Phone Number <br /> Luke Schmitz - —7 88412i 715-468-2434 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 160 Shell Lake W 154871 <br /> VIII.County[Department Ilse Only <br /> Approved ❑ Disapproved Permit Fee O Date Issued Issuing Agent Signatu <br /> ❑ Owner Given Reason for Denial $ 37- " 7- b " 1 <br /> IX.Conditions of Approval/Reasons for Disapproval ECEM <br /> R <br /> APR 24 2017 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches IMRNETT COUNTY <br /> I <br /> SBD-6398(R03/14) ��J ZONING <br />