Laserfiche WebLink
Safety and BuildingsLAVISIOn county BURNETT <br /> ` nr 201 W. Washington Ave.,P.O. Box 7162 <br /> isconsr►n Madison,WI 53707-7162 Site Addmss2 7 5 2 0 HILLS RD <br /> Department of Commerce <br /> Sanitary Permit Application Sanitary Permit Number (� <br /> In accord with Comm 83.21,W is.Adm.Code,personal information you provide C3 Check if Revision 459058 <br /> my be used for sewndary Purposes Privacy Law,s15. 1 m <br /> I. Application Information-Please Print All Information Sate Plan I.D.Number <br /> Property Owner's Name Parcel Number v 1 <br /> GARY 8 MARY NUSSBAUM Dag- qI -0a -`rJ <br /> Property Owner's Mailing Address Property Location Gov't.Lor 1 <br /> 8 BENT TREE COURT u A:S 36 T40 N R 14 � <br /> City,Stare Zip Code Phone Number tat Number 7 Bleck Number n a <br /> Subdivision Name CSM Numbe <br /> NORTH OAK, MN 55127 651 -483-3573 mz CSI,-, Vo2 . 1 , Pg . 205 <br /> II.Type of Building(check all that apply) ❑City _ <br /> 911 or 2 Family Dwelling-Number of Bedrooms 5 ❑Village _ <br /> ❑Public/Commercial-Describe Use (X7ownship SCOTT <br /> ❑State Owned Nearest Road <br /> HILLS RD. <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for.internal rase). Complete line B if applicable) <br /> qBO <br /> ❑ New 2 19 Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stemTank Onl Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wedand <br /> 22❑ Pressurised In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Gmde 46❑Aerobic Treatment Unset 49❑Recirculating 30❑Other <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Raw(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> 750 1071 . 43 1088 . 50 . 7 96 . 2 99.0x97. 0 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site S1 eel Fiber PI; tic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> K HoldtogTank 160 1600 1 Hubjcut.t Concnete X <br /> Dosing Chamber 700( 1000 1 n to X <br /> VII. Responsibility Statement- 1,the undersi d,assume res ib-'y for installation of the POWTS shown on the attached pians. <br /> Plumber's Name(Print) Plu r' igmm MP/MPRS Number Business Phon::Number <br /> EROY SANDRIDGE / I . D. # 224524 7.15-354-3882 <br /> Plumber's Address(Street,City.Sate.Zip Code) <br /> N1577 LONG LAKE AV . SARONA, WI 54870 <br /> VIII. County/De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing m tgmmre n ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Determination w30 v <br /> IX.Conditions of ApprovalfReasoos for Disapproval <br /> AUG 2 7 2004 <br /> Atmch complete plans(to the County only)for the system on paper not less than 81/2 s X11 iataYa Rpulqrf <br /> �V ZONING <br /> SBD-6398 (F2. 05/01) <br />