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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> Visconsin See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison,W153707-7302 Q <br /> Department of commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x I 1 inches in size. <br /> County Burnett S anitary Permit Number 01C if re ision to pre 'pus application State Plan I.D.Number �} <br /> �5-7 j,5 0. 993974 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> Mike Laqua GL 2 1/4 1/4,s T37 ,N,180or)w <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 115 18th Ave SE na na <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Cambridge MN 55008 (763 §89-1075 na <br /> II.Type of Building: (check one) ❑City <br /> EY 1 or 2 Family Dwelling-No.of Bedrooms: g <br /> ❑Villa e <br /> ❑Public/Commercial(describe use):_ P Town of Trade Lake <br /> ❑State-Owned <br /> Nearest Road Pine Lake Rd <br /> Parcel TaxNumber(s 1 nn_ <br /> III.Typeof Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. New 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> $) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground IN Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> 450 Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> ill 449.8 449.8i .6 na 98.20 99.95 <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> septic 1000 -- 1000 1 Wieser comb �p ❑ ° ° ° <br /> oLtnp 600 -- 600 1 Wieser comb <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) PI - Si to (no stamp MP/MPRS No. Business Phone Number <br /> Donald Daniels MP 330/221593 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 316 Siren WI 54872 <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued � nei afore stamps) <br /> XApproved 11 Owner Given Initial Adverse Surcharge Fee) 2 / <br /> Determination 3�:0S/J/Oi <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> 4 <br /> BUpN�� 2� <br /> SBD-6398(R.07/00) <br />