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eommeree.vA.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> i sen n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 540 Y7 <br /> Sanitary Permit Application State ction Number <br /> In accordance with s.Comm.83 21(2),Wis.Adm.Code,submission of this form to the appropriate governmental 7 I ,—,8 <br /> unit is required prior in obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if diffemat than mailing address) (� <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary :-j,�4/6 <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m Stats. Pepin Rd. <br /> 1. Application Information—Please Print All Information N <br /> Property Owner's Name Parcel# v V <br /> Mike and Valerie Na=il � 07-02$-2-110-14-34.5 05•005*-O/f/ <br /> ba <br /> 028-4134-03 604 <br /> Property Owner's Mailing Address Property Location <br /> 11369 Swallow Circle <br /> Govt Lot 5 %,%, Section 34 <br /> City,State Zip Code Phone Number (circle one) <br /> Coon Rapids MN 55433 612-298-9445 T 40 N; R 14 E or W <br /> Il.Type of Building(check all that apply) Lot# <br /> I or 2 Family Dwelling-Number of Bedrooms 1 4 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> 141• 15 PW f Town of Scott <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> `t' New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal 11 Permit Revision El Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com nent(Device: Check all that apply) <br /> r Non-Pressurized in-Ground ❑ Pressurized In-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersalfIrreatment Area Information: E-Z Flow-120311 Eiss Rating of 50.00 sq.ft. <br /> Design Flow(gpd) Design Soil Application RaWgpdsf) Dispersal Area Required(s0 Dispersal Area Proposed(so System Elevation <br /> 150 .60 250 300s If based on Eisa 94.77' <br /> Vl.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o'er 2 <br /> New Tanks Existing Tanks w e u <br /> R o <br /> aU h y h wC7 f% <br /> Septic or Holding Tank 750 750 1 Wieser Concrete X <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume mponsibifity,4 installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum s ignaW MP/MPRS Number Business Phone Number <br /> Robert Carlson <br /> MPI #135655 715-653-2500 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 3572 115th St. Frederic WI 54837 <br /> VIII.CountylDepartment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing ignature <br /> [I Owner Given Reason for Denial 3 5 711 �,nku- .201 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plow for the system and submit to the County only on paper not less than x ra x 11 inches in size <br /> SBD-6398(1—02/09)Valid thru 02/11 <br />