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OgrAaTBr ,T County <br /> Industry Services Division Bump <br /> 1400 E Washington Ave <br /> 3 $P Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 71112 <br /> � Madison,WI 53707-7162 S/}� -)S3 <br /> Sanitary Permit Application State Transaction N bet <br /> In accordance with SPS 383.21(2),Wis.Adm.Cotte,submission of this form to the appropriate governments]unit cou"V 1� !'c,"I;ew <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. 1 m),Slats. Mitchell Rd. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel 8 <br /> John Hansen 07-012-2-40-15-11-5 05-007-016000 <br /> Property Owner's Mailing Address Property Location <br /> 13981 Brunswick Ave.South <br /> Govt.Lot 7 <br /> City,State Zip Code Phone Number /,, /. Section 11 <br /> Savage,MN 55378 circle one) <br /> T40N R15EoS <br /> H.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> NA <br /> ❑PublicJCommercial-Describe Use Block f <br /> El City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> Vol. 10 Pg 237 ®Town of Jackson <br /> III.T of Permit: Check only one box on tine A. Complete line B ifapplicable) <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 mui 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 1n-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) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 300 Rate(gpdst) 429 450 95.30 <br /> .70 <br /> V1.Tank Info Capacity in <br /> u <br /> u <br /> Gallons Total #of Manullictmer � � � <br /> New Talcs Existing Tanks Gallons Units Y <br /> a U m y rn w t7 a. <br /> Septic or Holding Tank 750 750 1 Wieser Concrete ID ❑ ❑ ❑ ❑ <br /> Dosing Chamber 0 ❑ El ❑ <br /> VII.Responsibility Statement-1,the uadertdgn ume r b' for installs' n of the POWYS shown on the attached plans. <br /> Plumber's Name(Prim) s MP1WRS Number Business Phone Nurnber <br /> Dayton Daniels 007086 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> P.O.Box 326 Siren W154872 <br /> VIII.Compty.ADepartment Use Onl <br /> Approved I ❑ Disapproved Permit Fee 00 Date Issued Issuing Agent Si <br /> El Owner Given Reason for Denial s 3/S• �(p7t� A <br /> - <br /> IX.Conditions of Approval/Reasons for Disapproval �J <br /> P/'OPOS(O CLL COGtLJ,rON /S DN P�O�/ Gtt•N <br /> Se>G,da�Ks. `Ll` SEP 19 1092 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 r/2 a 11 inchesa�v)RNM COUNTY <br /> ZONING . <br />