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commerce.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> isco ns i n Madison,WI 53707-7162 SanitaryPermit Number(to be filled in by Co.) <br /> rtm <br /> Depaent of Commerce 5 3 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmerital <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are project Address(if different than mailing address) <br /> submitted.m the Department of Commerce. Personal information you provide may be used for secondary µ' I "� 1 <br /> ses n accerdartce with the Priv Law s. 15.04 1 m,Stars. 1 b g� DEet nth `-' � <br /> 1. Application Information-Please Print All Information Dee ath Addition/Vo al-e_r villa e <br /> Property Owner's Name Parcel# D/z 9250 33 700 <br /> Maksim Maksimov /) a2� / 0/2 9250 33 800 <br /> Property Owner's Mailing Address C J (� O�Z' 9250 3„3 90D <br /> 15132 Cherry Ln Property Location <br /> Govt.Lot <br /> City,State Zip Code one Number Section10 <br /> Burnsville,MN 55306 612.490-1110 (circle one) <br /> II.Type of Building(check all that apply) Lot# T 40N; R15 W <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> 317, 318 } 31q Voyager village/deer path addition <br /> Public/Commercial-Describe Use Block# <br /> El City of <br /> ❑ State Owned-Describe Use CSM Number ❑ Village of <br /> ® Town of Jackson <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System Replacement TremmenUHolding Tank Replacement Only _ Lj Other Modification to Existing System(explain) <br /> System <br /> B. Permit Permit Revision Change of Permit Transfer to List Previous Permit Number and Date Issued <br /> Renewal Before Plumber New Owner <br /> Ex iration <br /> IV. <br /> Type of POWTS S stem/Com onent/Device: Check all that a 1 <br /> Non-Pressurized In-Ground Pressurized In-Ground At-Grade Mound>24 in.of suitable soil Mound<24 in.of suitable soil <br /> ❑ Holding Tank [-]Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Trestment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 450 .7 642.86 651.6 <br /> 93 0� <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units °' <br /> V <br /> New tanks Existing Tanks .9 <br /> GC U <br /> Septic m Holding Tank 1000 1000 1 Wieser <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,a e res risibility r install on of the POWTS shown on the attached plass. <br /> Plumber's Name(Print) Plum ign MP/MPRS Number Business Phone Number <br /> Travis Butterfield 652879 (715)634-8176 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 14346 W State Road 77 Hayward, W15 43 <br /> V 11.Coon /Department Use Only <br /> Approved 11Disapproved IPermit Fee Date Issued Issuing ent Signature <br /> El Owner Given Reason for Denial S I '"(� V3-09 - Lfnat(` <br /> IX.Conditions of Approval/Reasons for Disapproval 1Jofb: SrE. oc-03 "re 3f?, 3/1 1 3 If Swer /04 S.ddrors/s». <br /> Attach to compk a pkm for the system sad sabmit u the Cowry only ori paper mt Iw duo 8 Irz z I i ivches in sae <br />