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Oor nierCC.W1.90V Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> tric sco n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Cc <br /> operl�ttof 53Z i ?3 <br /> Sanitary Permit Application State Transaction Numbers <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. Noce: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15. 1 m,Stats. 6461 Pike Bend Rd. <br /> 1. Application Information—Please Print All Information <br /> Property Owner's Name lotc..m avAer Parcel 8 <br /> Melissa Parker <br /> H56C AAK USA 7- F] 018-3326A5600 <br /> Property Owner's Mailing Address 3471P Sfd{�utcw $LuD Property location <br /> 5740 Irving Ave.North <br /> F'P. ' N I LL SG lj Govt.Lot <br /> city,state Zip Code Phone Number NE %,SW%, Section 26 <br /> Brooklyn Center MN 55430 612-492-7884 (circle one) <br /> T 39 N; R16 EorW <br /> II.Type of Building(check all that apply) Lot <br /> d I or 2 Fmnily Dwelling—Number of Bedrooms 2 1 Subdivision Name <br /> Block M <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State owned—Describe Use CSM Number ❑ Village of <br /> Vol.l Pg.68 11 Town of Meenon <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) O-�-0)9— <br /> A <br /> _A. ❑New System Replacement System ❑ TnbltmemMolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Pemrit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner 3 505 /O60'7 4-16- 93 <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> 0 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.Dispersal/Treatment Area Information: Infiltrator lAsching Chambers Quick 4 Standard-W Eisa Rating of 20.00 sq.ft. <br /> Design Flow(gpd) Design Soil Application Rete(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sq System Elevation <br /> 300 .7 428.57 440 Cell 1 =95.00' <br /> Cell 2=95.00' <br /> VI.Tank Info Capacity in Total 11of Manufacturer <br /> Gallons Gallons Units + <br /> New Tanks Existing Tanks P ii y ffi 3 fd <br /> 4 U in � h ii C7 i% <br /> Septic or Holding Tank 1000 1000 1 Wieser Concrete X <br /> Dosing Chamber 600 600 1 Combination X <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibiloy for Installation of the POWTS shows on the attached plans <br /> Plumber's Name(Print) Phuriper Si MP/MPRS Number Business Phone Number <br /> Robert Carlson <br /> MPRS#135655 715-653-2500 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 3572115"'St. Frederic WI 54837 <br /> VIII.County/Department Use Only <br /> Approved F1Disapproved Permit Fee late Issued /. Issuing t Si <br /> L1 Owner Given Reason for Penial $ J�5 3," <br /> a <br /> IX.Conditions of Approval/Ressors for Disapproval <br /> Attach to complete plass for the syssem and submit to the Coney only on paper not less dam 9 1a s 11 inch"In sire <br />