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V7 <br /> Sanitary Permit Application Safety&Bui dings Uivi <br /> 201 W. Washington le <br /> In accord«idt Comm 83.21. Wis. Adm. Code PO Box 7 <br /> Of <br /> . ^ See reverse side for instructions for completing this application <br /> Sep1Is�lt1 Personal information)on provide may he used for secondary purposes Madison, WI 53707-7 <br /> DenArtment ar eommerci lPrisacv Last. s. 15.04(I)(m)l (Submit completed form to county <br /> stale ow <br /> Attach complete plans(to the count) cop) only)fo the system,on paper not less than 8-1/2 x I I inches in size. <br /> County Stale itary Permit Number eck i revision to reviou. application State Plan ntber <br /> Burnett a 5 <br /> 1.Application Information - Please Print all nformation Location: <br /> Property Owner Name Property Location GL 1 <br /> Raymond E Johnson 1/4 l/4,s26 T38 NJ'I5 w <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 11300 Hampshire Ave S na na <br /> City Slate lip Code Phone Number Subdivision Name or CSM Number <br /> Bloomington MN 55438 ( ) -- na <br /> II Type of Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling--No.of Bedrooms ? ❑Village <br /> Town or LaFollette <br /> ❑ Public/Commercial(describe <br /> ❑ Slate-owned <br /> 111 T e of Permit: Check only one box on line A. Check box on line B if applicable) N ,,yre_st Road / <br /> YP ( Y <br /> A) L ❑New System 2. Replacement 3. ❑ Replacement of 4. ❑ Addition to Parcel Tax Nutriments) <br /> System 1 ank Onl � Existing System 1 014 — 2226 — 03 100 <br /> B) penult Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> KI Non-pressurized In-ground O Mound O Sand Filter ❑Constructed Welland <br /> ❑Pressurized In-ground ❑ 11.1ding Tank O Single Pass ❑Drip Line <br /> ❑At-grade ❑ Acrobic I reatment Unit ❑ Recirculating ❑Other: <br /> V Dispersal/Treatment Area Information: <br /> 1.Design flow(gpd) 2 Disper!250 <br /> lArea 3 Dispersal Area 4.Soil Application 5.Percolation Rate 6,System Elevation 7.Final Grade <br /> Required Proposed Rite(t,'als/daylsq. R.) (Min/inch) Elevation <br /> 300 265 1.2 na 94.50 97.00 <br /> VI Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons (Inks Con- Con- glass <br /> New Existing crete structed <br /> Tanks tanks — — ❑ ❑ <br /> W ❑ ❑ <br /> septic 1000 -- 1000 1 Wieser Concrete _ _ <br /> PUMP 600 -- 600 1 Wieser comb. <br /> VII Responsibility Statement <br /> 1,the undersigned,assume res onsibility for installation of the POW IS shown on the attached plans. B,rsiness Phnne Numher <br /> Plumber's Name(print) Plun cr's Signa one(n stamps) MP/MPRS No. <br /> Donald Daniels MP 330/221593 715-349-5533 <br /> Plumber's Address(Street,City.State,71p Cnde) <br /> PO box 316 Siren WI 54872 <br /> Vlll Connty/Department Use Only <br /> ❑Disapproved =Advets"e <br /> perms -cc(Includes Groundwater 74;/. <br /> Issuing ettt S' at ( stamps) <br /> pproved ❑Owner(livene Fe�bDetermination �"lll 2 <br /> IX.Conditions of Approval/Reasons for Disapproval: <br />