Laserfiche WebLink
E�yt AxTsrf,�l\ County <br /> at °' Industry Services Division Burnett <br /> 1 '71 (t 11 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 I,-- <br /> 7 Madison,WI 53707-7162 9JT� <br /> Q <br /> .n9rl 2vNk)w rt�. J <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Slats. 28892 West Yellow River Rd <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel 4 <br /> Steven Nordin 07-020-240-16-07-5 15-660-019000 <br /> Property Owner's Mailing Address Property Location <br /> 1427 Albert Street North <br /> Govt.Lot <br /> City,State Zip Code Phone Number SE'4,SW'''A, Section 7 <br /> St Paul,MN 55108 651-666-0797 circle one) <br /> T40N RI6Eo 1k <br /> 11.Type of Building(check all that apply) Lot# <br /> ® I or 2 Family Dwelling-Number of Bedrooms______ _ 10 Subdivision Name <br /> River Oaks <br /> ❑Public/Commercial-Describe Use Block 4 <br /> ❑ City of <br /> ❑State Owned-Describe I Ise <br /> CSM Number El Village of <br /> ® Town of Oakland <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System ❑ Replacement System ® Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit'I'ransfer to New List Previous Permit Number and Date Issu <br /> Before Expiration Plumber Owner Micas, <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ® 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: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required Is Dispersal Area Proposed(sf) System Elevation <br /> 300 Rate(gpdsf) <br /> VI.Tank Info Capacity in _ <br /> U <br /> Gallons Total #of Manufacturer U <br /> Gallons Units <br /> New Tanks Existing Tanis <br /> Septic or holding Tank 750 750 1 Wieser Comerete ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber I ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersign ssu ne responsi ility for instal 'on of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) is MP/MPRS Number Business Phone Number <br /> Davton Daniels ` 007086 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Y.O.Box 326 Siren WI 54872 <br /> V Il.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee_ O Date Issued I suin nt i ature <br /> ❑ Owner Given Reason for Denial $ 37s ' 3'�7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Pi/o�dtrtl Stp�;ee T Fr' T�i.�. �S JUN 30 2017 <br /> }�lo rrt Aje LL • BU <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x II inches in size ZONING <br /> SBD-6398(R03/14) l� <br />