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pi•mvayr Cowry <br /> Industry Services Division Bunten <br /> 1400 E Washington Ave <br /> $P P.O. Box 7162 Swim,Pwnit Number lwIx,filled in by Ca.) <br /> S� Madison,WI 53707-7162 57'13l'j <br /> �Vr - <br /> Sanitary Permit Application Stec Troosaaiw Number <br /> In reeardanse with SPS 383.21(2),W is.Adm.Cmk,submission of this form to to alrpropriau gnvemmcntal unit <br /> is required prim to obtaining a amitay permit. Note:Application(f steeuwrd POWYS we submitted to <br /> the Department ofSafty and Prof ional Services. Pawnai informatin you provide maybe used for secondary Project Address(ifdiR ni Nan nmiling address) <br /> maboxes in beeomanm with use Priv law,s.15,04(1 Xho,Stat. 209851 cwood Urrvc <br /> I. Application Information—Please Print All Information <br /> poopaty Owner's Name Parcel a <br /> Anthony and Annette Smebak 07-0348-37-18-21-5 05-003-016010 <br /> Propeny Owner's Mailing Address properly I.ocation <br /> 5112 Kahl Av, <br /> Cron Id 3 <br /> City,Sum Zip Code Phone Number Y., S, Seam,21 <br /> Albemille,MN 55301 (arcle one) <br /> T37N R18Emv/ <br /> II.Typeof8uilding(chtekallthatapply) Wtq <br /> ® I or 2 Family Uwalling—NtmNer of Bcdmors 3 l Subdivision Name <br /> ❑PublieK7mmnereial—Describe Use Block M <br /> ❑Stone CMnd—Describe Use ❑ City of <br /> CSM Number ❑ VNlhs'uf <br /> 3603 Vn, 18 P669 ® Townof Trde lake <br /> III.T e of Permit: (Cheek onl one box on line A. Complete line B itapplicable) <br /> A. ❑ New System ❑ Replacement System ®Treaans.01olding Took Replacanrnt Only ❑Other Modification to Existing Systan(explain) <br /> B. ❑ Permit Rrnewal ❑ peound Revision ❑Change of ❑permit Trnsfn to New List pve iso s Permit Number and Dole Issued <br /> Ilcro ,Expiraion plinth,' Dwawr <br /> IV.Type of POWTS S stem/Com onenUDevice: Check all that apply) <br /> ❑ Non-Pr¢wrvcd lrLmund ❑ Prrssudrd In{ nd ❑ AKimdc ❑ Mnd>24 to of w'aable soil ❑ Mound<24 inof sortable soil <br /> 011.1ding Tale ❑Otber Disperwl Component(explain) ❑P,eneamndt Deviee(explaia) <br /> V.Dispersairrreatement Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Rc,,mmd Is Disl . I Area proposed(at) System Elevatin <br /> 450 Rae(gpds0 No No Na <br /> No <br /> VI.Tank Info Capacity in <br /> Gallonsm <br /> ('�all ns Units Mooufacwxr — a R <br /> sorer trots exmiaa rade <br /> Septic or Holding Tank 20()0 2000 1 1 Wie.,Concrete ❑ ❑ ❑ ❑ <br /> Uusing ChamberEl ❑ EJ <br /> VII.ResponsibilityStatemenP 1,the undrnigod,assumr rtapnaribiliry for inrtallmioa of thr P(IW'Iti shown oe the an¢bd plans. <br /> Number's Name(print) Y ber/'s Sign MP/MPRS Number Business M.Number <br /> Dayton Danicls dt W7086 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> P.O.Box 326 Si.WI 54872 <br /> VIII.Coun /De amment Use Onl <br /> �Appmved ❑ UisappmveJ Permit Pee Date Issued Issuing Agent Sigod re <br /> ❑O ner Gwen Reason fm Denial 5 <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> �u Qu�s�vEWfS isrsrST Btu Z' oa �7r RE A3rU� QFE of D ECEOVE An <br /> 9// 0o Pp2 iRAgaeE <br /> Awash ro manses,qrn for rtr mum and submit re the County may ms pmr rot lam drum I m x N iso <br /> BURNETTCOUNTy <br /> ZONING <br />