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;;niofeo.t[vl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> ' n Madison,WI 53707-7162 Sanitary Permit Number(m be filled in bje. <br /> a <br /> Sanitary Permit Application Smte Transaction Number' <br /> In acconJanee with s.Comm.83.21(2),Wis.Adm.Code,submission of this form m the appropriate governmental <br /> wit is required prior m obtaining a sanitary permit. Nae: Application forms for stmcowaed POWTS are Project Address(if different man mailing <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,a.15. 1 m Stats. _ 29594 CCC Rd. <br /> I. Application Information-Please Print AB Information <br /> Property Owner's Name Parcel#Oq __ <br /> Richard and Melissa Mark �a 07-020-2-4o-16-02-5-15-26o-)12- <br /> Property Owner's Mailing Address Property Locative 030 <br /> 4653 Furopa Trail North Govt.Lot I <br /> City,State Zip Code Phone Number '/ti e/ti sued.2 <br /> Hugo MN 55038 55038 1(Brele aced, <br /> If.Type of Building(check all that apply) Let#P� T N; R E o <br /> e <br /> J 1 in 2 Family Dwelling-Number of Bedrooms 3 2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State owned-Describe Use CSM Number ❑Village of <br /> Vol. 12 Pg. 31 ®Townof Oakland <br /> M.Type of Permit: (Check only one box on line A. Complete Use B if applicable) <br /> A. ❑New System 9 Replacement System ❑Tmtment/Hokfmg Tank Replacement Only ❑Other Modification to Emstm8 System(explain) <br /> B. ❑Permit Renewal [I Permit Revision ❑ <br /> Change of Phmba ❑Permit Tmnafa m New Lin Previous Permit Number and Date Issued <br /> Before Expiration owner, <br /> 7IIV.Type of POWTSS tem/Com nt/Device: Cheek all that apply) n ret OT Quick - = 0R.0Q' <br /> m Non-I'm urized In-Ground ❑I'masmiud InGmund ❑M-Grade ❑Mound>24 in.of suitable soil ❑Monod<24 in.of smmble soil <br /> ❑Hoklmg Tank ❑Oaer Dispersal Component(explam) ❑Pregeamacm Device(explain) <br /> V.Dia reatment Arron Ioformation: <br /> Design Flow(gpd) Design Soil Application Raw(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> 450 1 .7 642.86 660.00 95.00 — 94.50 <br /> VI.Tank Info Capacity in Tonal #of Manufacturer <br /> Cmdlom Gatbns Untm °o u <br /> New Tumks Existing Tanks <br /> 6U .nm y 3� <br /> Septic or Holding Tank 1000 1000 1 Wieser /Concrete x <br /> Dosing Chunberoro o x <br /> VIL Responsibility Statement-I,the o assosse rugmodbilily for installation of the POWTS shown on the attacked pian. <br /> Plumber's Name(Print) Si MP/b1PRS Number Business Pkone Number <br /> Dayton Daniels O70 007086 715-349-5533 <br /> Plumber's Address(Street,City,Stan,Zip Code) <br /> P.O. Box 326 SirenWI 54872 <br /> I.Cour /De artmeat Use Only <br /> Approved ❑Diaepimved Permit <br /> -1Fee <br /> Dam-Issued limis Sigoatme <br /> ❑Owner Given Reaeonfa Donlal S3 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Aaaeh w eoaryW plass for the syalass sad aabNt 0 the Cesssy sob as paper eN len Use 3 in a 11 Pekes in use <br /> SBD-6398(IL 02/09)Valid thro 02111 <br />