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Safety and Buildings Division County Q <br /> Visconsin 201 W.Washington Ave., P.O.Box 7162 JVV.n C'G-6 <br /> Madison,WI 53707-7162 Sanitary Permit Number(to c filled in by Co) <br /> Department of Commerce (608)2663151 S 3 97 <br /> Sanitary Permit Application State Plan I D Number <br /> In accord with Comm 83 21,Wis.Adm.Code,personal information you provide / 79 111 / --�— <br /> may be used for secondary purposes Privacy Law,sl 5.04(I)(m) Project Address(if different i ban mailing address) <br /> 1. Application Information—Please Print All Information �.l- I^ 28811 Cty Rd. H <br /> Property Owner's Name 't1 �( Parcel# Lot is Block is U� <br /> Eugene Bryski Coffee Shop 07-028-2-40-14-09-3-04-000-015000 <br /> Property Owner's Mailing Address Property Location <br /> 1801 Hale Ave. SW SE <br /> Y, Ye, Section 9 <br /> City,Stale Zip Code Phone Number <br /> Oakdale MN 55128 T 40 N; R 14(cirele o e) <br /> 11.Type of Building(check all that apply) <br /> ❑I or 2 Fain ily Dwell ing-Number of Bedrooms ��-- Subdivision Name CSM Number <br /> Q Public/Commercial-Describe Use ,ZS Sie$, .2 3ost0/aysY TQC 5hol4 IFJI(�'`/ �O <br /> ❑State Owned—Describe Use []City []Village ownsl rp of Scott <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System 0 Replacement System ❑TreatmentMolding Tank Replacement Only 11 Other Modification to Ex i ting System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> 0 Non-Pressurized In-Ground ❑ Mound>24 inof suitable soil ❑ Mound<24 inof suitable soil ❑Al-Grade ❑ Single Pass and Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑ Aerobic'I reatment Unit ❑Recirculating San Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sD Dispersal Area Proposed(so System FI valion <br /> 450 .7 642 660 93 <br /> V1.Tank Info Capacity in Total Number Manufacturer Prefab Site S eel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Bolding rank 1000 1000 1 Wieser X <br /> Aerobic Treatment Una 1250 1250 1 Wieser X <br /> Dosing Chamber <br /> VI 1.Responsibility Statement- 1,the unders' o ed,an4 responsibility for installation of the POWTS shown on the attached plan s. <br /> Plumber's Name(Print) Plu is Sig MP/MPRS Number Business Phom Number <br /> Kelly Ferguson 11 1 224069 715-635-2887 <br /> Plumber's Address(Street,City,State,ZipCrPeT <br /> W9502 Dock Lake Rd., Spooner, WI 54801 <br /> VIII.Count /De artment Use Only <br /> Approved El Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin t Signature tamps) <br /> Surcharge Fee) ,.yy �r 'I <br /> ❑ Owner Given Reason for Denial `/f 325 ti7Ma7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less Man 81/2 x I l inches in sire <br /> SBD-6398 (R. 01/03) <br />