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dnaeuevr Cmmry . <br /> -�.� Safety and Buildings Division Burnell <br /> ))) D S o✓G 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(m be fined in by Co.) <br /> r P8( Madisoq Wl 53707-7162 U' <br /> $ss 55896 b <br /> Sanitary Permit Application StarsTr�mrweti/onNumber <br /> In accordance wa1sSPS 3g721(2),W u.nam Code,submission of Nis form to tbe apprupriak govemmrnml tmii UJon C vlaj I <br /> is"itired prior to oMaining a sanitary remain. Nine:Application forms for ztarerwaced PC)WTS arc submined W Project Addraz(if diR t Nm mailing address) <br /> the fix armant of Safely and Pmfexsionel Sanies. P<rvmnl information you provide may be used fru secondary <br /> twos m Kcordmce wuh Mn privpa hw,c 15 N4 m),Stan. 28491 Johnson Lake Rd. <br /> 1. Application Information-Please Print All Information <br /> property Gwwor•s Name Parcel d <br /> Mary Keller /,to -rl-3 07-020-2-40-16-14-5 05-001-011000 <br /> ProgenytTvmr•s Mailing Address (, Property location <br /> P.O. Be.473 <br /> GovL for I <br /> City.your, zip Cude Phwre Nmnber _v..,_'/., Section 14 <br /> Stillwater MN 55082 (circle one) <br /> IL Type of Building(check all that apply) Lwa "f 40 N; RIb Hr,� <br /> ®I ort Family Dwelling-Number of Bredrmms l 1 CSM.Vol.7 Pg. 199 Subdism.Name <br /> Black a <br /> ❑Publir/Camrrmcial-IMcdbe Use <br /> ❑Sure(Tined-Describe Use NA ❑airy of <br /> CSM Number C Village of <br /> Vol.7 Pg.199 ®1'nwnofOakland <br /> 111.Type of Permit: (Cheek only one box on line A. Complete line B if applicable) 0c2l) 14 <br /> A, ❑New System P Replacement System C Trairm.01oldfag Tank Re hreconcnt(Aly C (Ther Mtdification m Existing System(.Plain) <br /> B. C Permit Renewal C Parmit Revision C CTenge of plumber C Permit Transfer w Ncw List previous Permit Number and Daze Issued <br /> Before Expansion Cave" <br /> IV.Typc of POWTS S stem/Com nenUDevie: Check ell that apply) <br /> C NnrrPressurisd In-Grund C Pres surivml 1.4round ❑At<'.mdc ❑Mound>24 in.ofsuamble soil C Mound<24 inof witable mal <br /> 01-Iolding Trunk C Gdcr Dispersal Cornpoom,(explain) ❑ROmatmmt Device(explrum) <br /> V.Dispals.1frocrament Area Information: <br /> Design plow(gpd) Design Snil Application Ratngwfa0 Daspasal Area Required(s0 Dispersal Area Notarial(s0 System Elevation <br /> 450 Na Na Na Na <br /> V1.Tank Info Capacity in Total Nof Manufacturer <br /> Gallons GNlom Unan c c v u <br /> New Tmkr [aiaioF TmLa c +� <br /> $e,ciHa1ding1ivh 2000 2000 Wieser Concrete WLP R <br /> IbsinacLambv <br /> VII.ResponsibilityStatement- 1,the undcnign<d,mvm<mpoasi Iliry for installatge of Ib<POWTS shmwv on the aaacbed plass <br /> Plumber's Name(part Plu sS MPIMPRS Numb Dmirxas Phone Nmnbe <br /> Robert Carlson %• ,, ` 135655 715-653-2500 <br /> Number's Address(StrccL Cary,State Zip Cade) (�K <br /> 3572 1156 SI. Frederic WI 54837 <br /> VIP.Coun /De arlment Use Only <br /> Approved C Disapproved permit Fe< I}ete Issued Issuin�Signazum <br /> S <br /> ❑(Tvmr Givrn Rcawn fm ih ial I 7 <br /> IX.Conditions of Appro"UReasons for Disapproval <br /> 154 is nd(.f, 9t: Tor d Sol/ (G/(r slat fa .SG�{r(k /fNsEf d•vf D � � l:lE <br /> p+SaG late-r:ot/ Lpa�rEr[Ms LI <br /> Y 2 4 2013 <br /> Actual,w en.tdee poen ter red:)stem gad-ba+h to Weeamry eely oe ppe.art seraMoa F to r it f <br /> "star <br /> BURNETTCOUNTY <br /> ZONING <br />