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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> 1*sconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> 90 <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> Coun State Sanitary Permit Number O C ck if revision to previo application State Plan 1.D.Number <br /> ( 90 10,5 28 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> Cary & Ruth Pedersen GL 5 1/4 1/4,05 T40 ,N,4 Sar)W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 6128 Sherman Circle 4 na <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Edina MN 55436 ( 952-992-0753 Vol 1 P9 161 <br /> II.Type of Building: (check one) 0 city <br /> 1A 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑Public/Commercial(describe use): X9 Town of Jackson <br /> ❑State-Owned <br /> NejWdSouth Shore Dr <br /> Parcel Tax Number(012-4235-05-800 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. [A Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> ❑Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground CX Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 450 na na na na holdin tank <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> KI ❑ ❑ ❑ ❑ <br /> 2000 -- 2000 1 Wieser Concrpt ! <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> Donald Daniels MP 330/221593 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 316 Siren WI 54872 <br /> IX.County/Department Use Only <br /> �� ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issui A nt Signatureps) <br /> Gd Approved 11Owner Given Initial Adverse Surcharge Fee) <br /> Determination U /0 5W67 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> yu- <br /> SEP 9 2004 <br /> COUNTY <br /> ZONING <br /> SBD-6398(R.07/00) <br />