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warxmagruComity <br /> Safety and Buildings Division Burnett <br /> j D 1 201 W.Washington Ave., P.O.Box 7162 Sanhogy Penal Number,no be filledin by Co.) <br /> Madison,Wit 53707-7162 <br /> S <br /> Sanitary Permit Application scene TvuionNumber U <br /> In acconbmcc with SRS 383.21(2),W is.Adm.Code,submission or this form to the,appropriate govemmrnul unit e�v k,Gni <br /> is required prior to obtaining a sanitary wount. None.Application Gums f r awe+tweed IOW l S art submiac4 no RqM Addmss(ifi iRrrtnl than mailing raddras) <br /> the UCDmuaem of Safety and Rofmsiunaltiervies. Personal informffiirm you provide may be used for secondary <br /> in accordance with the Riv law,s. 15. I m,Mi 11437 State rd.48 <br /> I. Application Information-Please Print All Information <br /> proprny 1Tvper's Name Parcel d <br /> Charles and Gina Reese j 07-034-2-37-I8-27-5 16065-019000 <br /> lu 034-9CxD5- 02-000 Lquy t.o. <br /> Propeny Owner's Mailing Address Property Location <br /> 520 south Shore Drive <br /> (Jost.1,M <br /> cit,lura zip Code Phune Number _6._'/.. Senirnt 27 <br /> Forest Lake MN 55025 (eircleme) <br /> U.Type of Building(cheek all that apply) Intal 'f 37th; R18Eu�w <br /> Df 1 or 2 Family Dwelling-Number of Bednwms 2 Unit Subdivision Name <br /> Burke rearm Condominium <br /> Ilkrck p <br /> ❑Poblid ommmeial-Describe Use <br /> 11 More Owned-Diatribe Use NA 11 City of <br /> CSM Number C1 village or <br /> No ®Town afT.de Lekc <br /> III.Type of Permit: (Check only one box an line A. Complete line B ifapplicable) <br /> A. a New Sys.. ❑ Replacement System ❑1'teatmenVNulding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑permit Retctsal ❑ Permit Revision ❑Chatge of Plumber ❑Permit Trans'fa m New List Rcviom Penni)Number and Usk Issued <br /> lemon Expiration (honed <br /> IV.Type of POWTSS stem/Com one.UDevice: CM1ecit all theta I <br /> ❑ Non-PmsurimJ lr-0mund ❑ Presurived ln-Gmund ❑At+lmde ❑Moral>24 in,orsuitable soil ❑Mound<2A in ofsuiuble snit <br /> 0 (holding"rank ❑Other 1Sspmsal Component(explain) ❑PrORetment Devito(explain) <br /> V.DinitconflIT,catment Area Information: <br /> Design Flow(gpo) Design luil Application Rau(gp&Q Depersal Mea Required(sD Dispersal Area proposed(so System Elevation <br /> 450 Na Na No Na <br /> VI.Tank Info Capacity in Total d of Manufacturer <br /> Gallons Gallons Units <br /> UL a � <br /> New TanNr lixering TonkIs <br /> a - <br /> iZ <br /> Seine Or Bolding Tank 2000 2000 Wieser Concrete WLP X <br /> D-un,chamM <br /> VII.Responsibility Statement- L the undersigned,.,27 res abili r installation ufthc P01VTS, shown a a the attached plana. <br /> Plumber's Name(vdn0 No r MP/MPkS Numbed Business Pham Number <br /> Robert Carlson 135655 715-653-2500 <br /> Plumber's Address(Stan,city,stmt,J.ip Cudc) <br /> 3572 11510 St. Frederic WI 54837 <br /> � <br /> V,I/II.Count /De artment Use Only <br /> ';^ppmvrd ❑ Dist,rovea Perms Fee Date IsunJ Issuing se igrome" <br /> s r p <br /> ❑Owner Given Ronson for lymial 3 7J !W r/.TWIC 203 <br /> IS.Conditions of Approval/Reasons for Disapproval n <br /> slEe IS f. awe Of 60hast &e.. z'nc A F/rxa(II" <br /> Anarb to complete Ours tend, and aobuir to on,Covets only an piper sot Iona Wo I in a I I irabn in on <br />