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Safety&Buildings Division <br /> YRPSanitaryPermit Application 201 W.Washington Ave. <br /> �rlscorisln pp 15 Box 7302 <br /> In accord with Comm 83.21,Wis.Adm. Code Madison,WI 53707-7302 <br /> Department et Cammerc a Personal information you provide may be used for secondary purposes (Submit completed form to county if not <br /> [Privacy Law,s. 15.04(lxm)] state owned.) <br /> Attach complete plans to the county copy only)for the system.on paper not less than 8-1/2 x 11 inches in size. <br /> County State Samt Permit Number ❑Check if revisi previous application State Plan 1.D.Number Q j <br /> Burnett 3 8 R� . M 8a 638028 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> Herman Schulte <br /> GL 2 1/4 1/4,S2 T 37,N,Rl8E'eor)W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 2375 Chippewa Circle na na <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Maplewood MN 55109 ( 651 777-8998 na <br /> II Type of Building: (check one) ❑City <br /> -�ff 1 or 2 Family Dwelling—No.of Bedrooms: 2 ❑Village <br /> ❑ Public/Commercial(describe use): (3Town of Trade Lake <br /> ❑ State-owned <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road Spirit Lake Rd E <br /> A) 1. ❑New System 2. E Replacement 1 3. ❑Replacement of 4. ❑Addition to Parcel Tax1lumbet(s) <br /> System Tank OnIv Existing System 034 — 1502 — 01 700 <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> ❑Non-pressurized In-ground ❑Mound ❑ Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground $1 Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.DispersalArea 3.Dispersal Area FSoilcation 5.PercolationRate 6.System Elevation 7.Final Grade <br /> 300 Required Proposed ay/sq.ft.) (Min./inch) Elevation <br /> VI Tank Capacity in Total #ofufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons TankCon- Con- glass <br /> New Existing crete structed <br /> Tanks I Tanks <br /> holding tank 2000i 2000 1 Wieser concrete <br /> VII Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) P tuber's Si afar (no stam s): MP/MPRS No. Business Phone Number <br /> Donald Daniels MP 330/221593 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 316 Siren WI 54872 <br /> VIII County/Department Use Only <br /> ❑Disapproved I Sanitary Permit Fee(Includes Groundwater Date Issued Issuing A ign a(No ) <br /> 675p—proved ❑Owner Given Initial Adverse Surcharge Fee) ( /�IQ <br /> Determination 1 11 <br /> IX. Conditions of Approval/Reasons for Disapproval: <br />