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eommeree.Wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave..P.O.Box 7162 Burnett <br /> Madison,W153707-7162 Sanitary Perm it Number(to be filled in by Co <br /> �sconsin .) <br /> Department of Commerce <br /> Sanitary Permit Application Spite Transaction Number JJ <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 Project Address(ifdifferent than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary a`nry'(�F <br /> purposes in accordance with the Privacytaw,s. 15.04(1 m),Stats- Bergman rQlnt Dr. <br /> 1. Application Information-Please Print All Information <br /> i <br /> Property Owner's Name ,/-�- Parcel# <br /> Troy Martenson �� 7 I I 67-034-2-37-18-02-S 05wl-02!/ <br /> Property Owner's Mailing Address Property Location <br /> 6715 Meadowlark Court Govt Lot 1 <br /> City,State Zip Code Phone Number - ��4, iy Section 2 <br /> Lino Lakes MN 55038 612-308-3395 (circle one) <br /> 11.Type of Building(check all that apply) Lot# T 37 N; R 18 E or W <br /> -1 <br /> 91 or 2 Family Dwelling-Number of Bedrooms 3 1 Subdivision Name <br /> Block q <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> El State Owned-Describe Use CSM Number 3GJ /7 ❑ Villageof <br /> Vol 23 aye /¢ (Town of Trade Lake <br /> III.Type <br /> of Permit: (Check only one box online A. Complete line B if applicable) <br /> A_ Lof New System ❑ Replacement System ❑ TreatmendHolding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> R. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS Svstem/Com onent/Device: Check all that apply) <br /> ,�,/ <br /> ❑ Non-Pressurized In-Ground El Pressurized In-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil ILf Mound<24 inof suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V-Dispersal/Treat ment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sH Dispersal Area Proposed(sH System Elevation <br /> 450 1.0 450 450 99.5 <br /> VI.Tank Into Capacity in Total qof Manufacturer <br /> Gallons Gallons Units c a <br /> ° u _ <br /> New Tanks Fxisang Tanks w & n A <br /> v o v <br /> v- J a <br /> Septic of Holding Tank 1000 1650 1 Wieser X <br /> Dosing Chamber 650 <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Rick Brown ' 231251 419-0739 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 319 Badger Rd. Rice Lake WI 54868 <br /> VIII.Conn /De artment Use Only Approved ❑ Disapproved Permit Fee Date,,I/Issued IssuingA ignature <br /> ❑Owner Given Reason for Denial $ /8 N,a4h 2{//0 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> S/�C 15 /ntllGefxr( � of �/t70�///akn on F/aad Xazart.t 8cw.(evN Nd(� a(ofr.0 / i �v9 1uo8 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 lax 11 inches in size <br /> SBD-6398(R.02/09)Valid thru 02/11 <br />