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- - - <br /> /�/� Safety end Uuildirigs Diviriun County <br /> Ins- <br /> W.Washington hnx 716) Burnett <br /> Madison,W153707 7162 Sanitary Potmit Number(to bA Co)) <br /> (609)266-31514- 5,'80 <br /> _ Department of Commerce -_-_ <br /> Sanitary (Permit Application Stem Plan I.D.Numbcr <br /> In emortlwiM Comm 83.9,Wis.Adm.Code,personnel infarmmimi yon provide, 1287910 <br /> may be road fes accondary purposes Five,Taw,c 1504(1 xm) Project Address(if diNercnttI. Applintiovinformation-Please print Alllnformat <br /> ion 24666 Larrabee <br /> _ 3iI _ <br /> Property Ovnxa'a Neme 1`mcd 11 Tat 13111 is <br /> Dana & Barb Daniels 014-9075-01 100 Lot #7 <br /> Prop"owner's Mailing Address -... Propane luearon <br /> 10137 Chestnut Lane ,. ,. Sertion 5 <br /> city,Sten Zip Code Phone Number <br /> Brooklyn Park, MN 55443 T38 N; R15(nedo W ) <br /> --- <br /> rick all <br /> n.Im2 aodyDweg(c-Numberthat apply) <br /> hnnam Subdivision Name CSM Numle, <br /> ®Im2FemilY Dwelling-Number nfandnmms_ 5. _ <br /> ❑Public/Commemial-Describe Use _ Viola Lake Sub' <br /> ❑State Owned_Dmodbe Um Ilcny_[lvdb,r KTownship of LaFOI Tette <br /> ID.Type of Permit: (Cleeknnlyone n nnlinc A. Coce,korlinali fappReable) <br /> A. ❑Now 3ymmm aRepIecementSwims, Tremmrout lndin I ank Redacememt OnlY ❑Ulber Mudlbcmiun to kxisin S <br /> Ynm <br /> B. ❑PmnitRmawal ❑Permit Revision I �Change of [j 1'rnni,fursrn nNcw 1,10 Revbms P ..en Number and Date lward <br /> ITefine Expired. (`lumber Owner <br /> IV.Ty,efPOWTSSyntactic Chakall the,apply) <br /> 11 Nam le,-Gamord 14 Mound?24 in,ofsuilahle soil ❑ Mound,24 in.ol'suiabl.soil ❑ AI-Geode ❑ Siegle.Pass.4and Filter [l <br /> CaluWdWWetlend ❑Pretesudadle-Ground ❑ holding Tank 011cm1'ilm, ❑ Amoblulleahment Unit I l Rcrimuladng Send Filter ❑ <br /> R.mWehng Symhrlie Media Filf ❑IRwhing Chambcr [Drip-c, ❑Gravel-less Pipe ❑01bm(cxplain) <br /> V.Dia mmiltreentment Aru Information: _ <br /> Cosily,Flow(gyd) Deaigo Soil Application Rumbxisl) nisp d Area occurrel(a0 Diratsal arra Proposed(rp srrtem l9evabnn <br /> 750 .5 750 750 101 .30' <br /> VI.Tank lnfo Capaeily in 'foal Number Mwmfctmci 1'mGh Site Steel FiM1cr Plastic <br /> Gallons Gallons of Units Concerts Cnnstmcted Glms <br /> New 8c'adang <br /> Tuts TeM <br /> "adow"nahg,ut 12501 - 1250 . 1 _ ._Wieser Go t(v - <br /> AuebkhrmnmaUlm - -- <br /> 1000 - 1000 -1 Wieser Concrete X <br /> Vn.Itesponsibility Statement-1,the undersigned,assume responsibility for installation of the POINTS shown on the attached Plans. <br /> Plumber's Name(Print) Plumber's Signature IiMPMPRS Numbr iTuzinms Mone Number <br /> Dayton R Daniels __ _ - 007086/11600 715-349-5533 <br /> Plumbrr'nAddeeM(Stuart,city.State.zip Code) <br /> 24056 St. Rd. 35, P.O. Box 31_6, Siren, WI 54872 <br /> VID Counly_"partmeart Uae Onl <br /> Approved ❑Disapproved -Sanitary Permit Fee(includes Groundwater Date Issued Issuin 13igna Sumps) <br /> Suelenp Fee) <br /> ❑thvnm Gives Reason fqr Dmiial �_` Soo V/ CAa-y � _. <br /> IX.CondlNoea of ApProwl/leeteana Nr Uieapproval <br /> Atbeh rnmPteh Plrm Vo rhe Gunh only)for 1M vYnlem w Paper nm Iw than 812�11 iorhn in riff <br /> SBD-6398(R. 01/03) <br />