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Cot nlaorce.wl.gov Safety and Buildings Division County <br /> M 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> ' Co11r1n !rCn Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> 5,21 / 83 <br /> Sanitary Permit Application State Transaction Number / 11 <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental 9,,-Uie4d 1�IWNI <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) rV1 <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary Pike Bend Rd. <br /> purposes in accordance with the Privacy Law,s.15. 1 m,Stals. <br /> L Application Information-Please Print All Information <br /> Property owner's Name Parcel# 0/8 33,27 �/ 900 viOM"t <br /> Jerry <br /> AGGoetz k� <br /> Property(Tuner's Mailing Address Property Location <br /> 7826 Upper 26'h St.North <br /> City,State Zip Code Phone Number NE'/.-SWl/4 Section Q'7 <br /> Oakdale MN 55128 (circle one) <br /> T 39 N; R16EorW <br /> 11.Type of Building(check all that apply) Lot p <br /> I or 2 Family Dwelling-Number of Bedrooms 2 /AY4Q� ,I 7Subdivision Name Or7_ 0Ig-a -3q-lp" <br /> Blockp —a�0 �� Qa <br /> ❑Public/Commereial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of Meenon <br /> IIL Type of Permit: (Check only one boa on line A. Complete line B if applicebk) <br /> A. New System ❑Replacement System ElTreatmenUHolding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B• ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer m New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV. <br /> ]ype of POWTS System/Component/Device: Check all that a 1 <br /> O 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) C. pj /-14 ❑Pretreatment Device(explain) <br /> V.Dis ersaUTreatment Area Information: Infiltrator Quick 4 Standard-W Leaching Chambers <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Arae Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 .5 Epp 600 aq.fL Based on Elea s ST' al =96.75'CeIW2= <br /> 20.0 z 30 Chambers 96,75' <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units <br /> New Turks Existing Tanks f1 t; J <br /> �U rn A ii0 a <br /> septi`or Holding Tans` 1000 1 1000 1 Wieser Concrete z <br /> Dosing Chamber 600 1 600 <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans <br /> Plumber's Name(Prim) PI ber's Si ature MP/MPRS Number Business Phone Number <br /> Dayton Daniels [ l � D MPSI 007086 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) Cl/ <br /> P.O.Boz 316 Siren WI 54872 <br /> VIII.County/Department Use Only <br /> Approved 11 Disapproved <br /> Permit Fee <br /> Issued Issuing Signmm <br /> ❑ Owner Given Reason for Denial 3eZVP 131 Mit Og <br /> UL Conditions of Approval/Remmus for Disapproval <br /> Attach m tompkte plans for the syehm sad wbmk in the County mly as paper ant ku than a In x 11 iaehes in sift <br />