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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> `*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 /> 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 /> County Burnett State Sanitary Penn tuber 13 Check if rev' ion to previous ap ication State Plan I.D.Number <br /> I jw;a 03 69 ea 785266 <br /> I.Application Information-Please Print all In rmation Location: <br /> Property Owner Name Property Location <br /> Pat Marren GL 8 1/4 1/4,s 25T38 ,N,11U,(gF)w <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 727 Willow Lane 1 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Mendota Heights MN 55118 ( 651 )687-9121 Vol 1 Pg 71 <br /> II.Type of Building: (check one) ❑City <br /> W 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> Q Town of Wood River <br /> ❑Public/Commercial(describe use):_ <br /> ❑State-Owned <br /> Nearest Road <br /> Zetterberg Rd <br /> Parcel Tax Number(s)042-2525-06 200 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. E9 New 2. ❑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 53 Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑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 /> 450 450 450 .5 na 100.30 102.07 <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 /> 1000 -- 1000 1 Wieser Concrete ❑ ❑ <br /> 600 -- 600 1 Wieser �8grete ❑ ❑ ❑ ❑ <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) PI ber s Sign tore o 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( clud s Groundwater Date I ued Issuing ge Signa re <br /> *Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination V <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />