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mer Hr+r \\ <br />J ~r �� <br />Industry Services Division <br />County <br />Burnett <br />Sanitary Permitumberjto be filled in by Co.) <br />SAW- 19-IFY <br />(� <br />1400 E Washington Ave <br />P.O. Box 7162 <br />hJ <br />Madison, WI 53707-7162 <br />09 380 C-57-6`12_7 <br />Sanitary Permit Application <br />State Number <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />,Transaction <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />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 />23871 Azorah Lane <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />I. Application Information — Please Print All Information <br />Property Owner's Name <br />Parcel # <br />Kathleen Van Danacker <br />07-008-2-38-14-18-5 05-008-013000 <br />Property Owner's Mailing Address <br />Property Location <br />2244 Hale Ave. North <br />Govt. Lot 9 <br />'/4,/4, Section 18 <br />City, State <br />Zip Code <br />Phone Number <br />Oakdale, MN <br />55128 <br />651-271-2898trcle <br />one) <br />T38N R14Eg5 <br />11. Type of Building (check all that apply)T <br />Lot # <br />® 1 or 2 Family Dwelling — Number of Bedrooms 1 Wo <br />9 <br />Subdivision Name <br />❑ Public/Commercial — Describe Use <br />Block # <br />❑ City of <br />❑ State Owned — Describe Use <br />❑ Village of <br />CSM Number <br />Vol. 4 Pg. 108 <br />® Town of Dewey <br />III. Type <br />of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />® Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />B. <br />Before Expira ion <br />Plumber <br />Owner <br />1O 4R <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 <br />❑ 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) <br />Design Soil Application <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />300 <br />Rate(gpdsf) <br />500 <br />EISA 500 <br />C-1= 94.50'C 2 = 93.50' <br />.6 <br />VI. Tank Info <br />Capacity in <br />C „0 <br />Gallons <br />Total # of Manufacturer <br />9 <br />U t - <br />New Tanks <br />Existing Tanks <br />Gallons Units <br />0 c <br />a U <br />y <br />ri ti J. C7 <br />G. <br />Septic or Holding Tank <br />750 <br />750 1 Wieser Concrete <br />® <br />❑ ❑ ❑ <br />❑ <br />Dosing Chamber <br />❑ <br />❑ ❑ ❑ <br />❑ <br />VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />PIUTQIS Si <br />MP/MPRS Number <br />Business Phone Number <br />Dayton Daniels <br />007086 <br />715-349-5533 <br />Plumber's Address (Street, City, State, Zip Code) <br />P.O. Box 326 Siren WI 54872 <br />VIII. Coun /De artment Use Only <br />pproved <br />k <br />ElDisapproved <br />Permit Fee d <br />0 <br />Date Issued <br />Issuing Agent Signature <br />El? Owner Given Reason for Denial <br />$ J %S' � <br />/ <br />IX. Conditions of Approval/Reasons for Disapproval <br />APPROVED <br />EE WE <br />ID <br />Attach to complete plans for the system and submit to the County only on paper not less than 9/2 x inches m siz <br />BURNETT COUNTY <br />SBD -6398 (R03/14) ZONING <br />