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commerce-wi.gov Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O.Box 7162 Burnett <br /> i seo n s i n Madison,W1 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Depar6neM of Commerce 6 <br /> Sanitary Permit Application State Transaction N ber <br /> In accordance with s_Comm 83 21(2),Wis_Adm_Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note. Application forms for state-owned POW I'S are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may he used for secondary 3794 Rainbow Circle <br /> u oses in accordance with the Privacy Law,s. 15.04(I)(m),Slats. <br /> 1. Application Information—Please Print All Information <br /> Property Owner's Name / / Parcel# <br /> Chad and Jennifer Tjepkes 012-9525-04 400 <br /> Property Owner's Mailing Address l(/ / ' Property location <br /> 9148 Woodhall Crossing North <br /> Govt.Lot 2 <br /> City,State Zip Code Phone Number Section 11 <br /> Brooklyn Park MN 55443 763-391-7835 (circle one) <br /> T 40 N; R1$EorW <br /> IL Type of Building(check all that apply) Lot# <br /> N I or 2 Family Dwelling-Number of Bedrooms 4 34 Subdivision Name <br /> Block Rainbow Pond Add.to Voyager Vill. <br /> F1 Public/Commercial-Describe Use <br /> ❑ City of <br /> Ll State Owned-Describe Use CSM Number F1Village of <br /> 0 Town of Jackson <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System LL Replacement System ❑ Treatment/Holding Tank Replacement Only 11 Other Modification to Existing System(explain) <br /> B. L Permit Renewal [I Permit Revision ❑ Change of Plumber ❑Permit"Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> 6 Non-Pressurized In-Ground ❑ Pressurized In-Ground Ll 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.Dispersal/Treatment Area Information: Infiltrator Quick 4 Standard-W Leaching Chambers <br /> Design Flow(gpd) Design Soil Application Rate(gpds0 Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 600 .7 857.14 900 sq.ft.Based on Eisa of Cell#1 =88.80' Cell#2= <br /> 20.0 x 4s Chambers 87,10' Cell#3=85.90' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units .9 <br /> New Tanks Existing Tanks <br /> a U y 2 rn i02 <br /> + U a <br /> Septic or Holding Tank 1250 1250 1 1 Wieser Concrete x <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigue ,as me r po . i' ' <br /> or installs on of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) P 's Si atl�IV MP/MPRS Number Business Phone Number <br /> Dayton Daniels ) � MP#007086 715 349-5533 <br /> Plumber's Address(Street City,State,Zip Code) <br /> P.O. Box 316 Siren WI 54872 <br /> VCourt /Department Use Only <br /> dpprovn <br /> Ll Disapproved Permit Fee Date Issued Issuing n ignature <br /> F1 Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In x 11 inches in sire <br />