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CoITImercemi.gov Safety and Buildings Division County <br /> 111 <br /> 201 W. Washington Ave.,P.O.Box 7162 Burnett <br /> tLartment of Commerce cons�n Madison,WI 53707-7162samim P¢m Nnmwrom meedimbycm1 <br /> Sanitary Permit Application Stateiransaction✓Number <br /> In accordance with s.Comm.83.21(2),Wis-Adm.Code,submission of this form to the appropriate governmental 1754970 <br /> unit is required prior to obtaining a sanitary permit Note, Application forms for state-owned POWTS are <br /> submitted to the Department of Commerce. Personal information you providemay be used for Project Address(if differentthan mailing address) <br /> u ses in accordance with the Privac Law,s. 15.04 1 m,Stats. secondary <br /> I. Application Information-Please Print All Information Bergman Point Dr. <br /> Property Owner's Name <br /> Troy Martenson Parcel <br /> Property Owner's Mailing Address Wt a 07-034-2-37-18-02-5-05-001- <br /> 6715 Meadowlark Court Property <br /> Location <br /> Govt Lot 1 Qa/o�i{f(� <br /> city,State Zip Code Phone Number <br /> Lino Lakes MN 55038 — Section 2 <br /> 612-308-3395 (circle one) <br /> H.Type of Building(check all that apply) Lot g T 37 N; R 18 E or W <br /> or 2 Family Dwelling-Number of Bedrooms 3 1 Subdivision Name <br /> ❑Public/Commereial-Describe Use Block M <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ village of <br /> 394417 Town of Trade Lake <br /> AIII.Type of Permit: (Check only one boson line A. Complete line Bit applicable) <br /> . <br /> ew System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. Permit Renewal ❑ Permit RevisionChange of Plumber List Previous Permit Number and Date Issued <br /> ❑ ❑P¢rmit Transfer to New <br /> Before Expiration Owner <br /> 1 V.T e of POWTS 5 stem/Com onen1/Device: Check all that a 1 �3.2 X5-6 j -/9- /V <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil ,Mound<24 inof suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) <br /> ❑Pretreatment Device(explain) <br /> V.Dis ersaVTreatment Area Information <br /> Design Plow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dis rsal Area Pro <br /> 450 1 .0 450 450 99.5 <br /> Pe posed(sf) System Elevation <br /> VI,Tank Info Capacity in Total a of <br /> Manufacturer <br /> Gallons <br /> Gallons Units <br /> New Tanks Existing Tanks a 2� o � - <br /> m <br /> Septic or Holding Tank100D <br /> i V 7, 2 in U <br /> Dosing chamber 600 1600 1 Wieser X <br /> VII.Responsibility Stateent- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) mPlumber's Sguipure <br /> Jr/(�� MP/MPRs Number Business Phone Number <br /> Rick Brown kL 231251 419-0739 <br /> Plumber's Address(Street,City,S[a[e,Zip Code) <br /> 2060 17 1/2 Ave. Rice Lake WI 54868 <br /> VIIL Coun /De artment Use Onl <br /> Approved ❑ Disapproved Permit Fee <br /> Fee Dateissued Issuing Signature <br /> El Owner Given Reason for Denial .- tw& <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on per not less than soy a 11 i <br /> s <br /> MAR 2 0 2012 <br /> SBD-6398(R.02/09)Valid thou 02/11 SURNM COUN1Y <br /> ZONING <br />