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cornmerceml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> yfiseonsin Madison,WI 53707-7162 Sanitary Permit Number Ho be filled in by Co.) <br /> Department of Commerce 4 8�579 <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 governmental 1413201 <br /> unit is required prior to obtaining a sanitary permit. Note: Application lomss for state-owned POWTS are Project <br /> CAddress(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary 24651 Anchor Inn Rd <br /> purposes in accordance with the PrivacyLaw,s.15.04 1 m,Stats. <br /> 1. Application Informstion-Please Print All Information ri <br /> Property Owner's NameParcel# <br /> John M Peterson ;43Q a 014-2205-03 160 <br /> Property Owner's Mailing Address Property Location <br /> 14030 Dartmouth Pa Govt.Lot 2 5 <br /> City,State Zip Code Phone Number /, /, Section <br /> Rnseinnunt MN 55068 651-795-9689 T 38N N: R1 5 (circlE on <br /> or�1 <br /> 11.Type of Building(check all that apply) Lot# <br /> I Subdivision Name <br /> IX 1 or 2 Family Dwelling-Number of Bedrooms <br /> Block ft CSM Vol 20 Pg 168 <br /> D Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number D Village of <br /> V/e a 0 e I / <br /> I/[iLS_[J X,Townof I aFnl lotto <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' <br /> IN New System D Replacement System D Treatment/Holding Tank Replacement Only D Other Modification to Existing System(explain) <br /> B. D Permit Renewal D Permit Revision ❑ Change of PlumberPerList Previous Permit Number and Date Issued <br /> ❑ mit Toaster nsfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> D Non-Pressurized In-Ground D Pressurized In-Ground D At-Grade R Mound>24 in.of suitable soil D Mound<24 in.of suitable soil <br /> D Holding Tank D Other Dispersal Component(explain) D Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(-a Dispersal Area Proposed(at) System Elevation <br /> 750 500 °._0 Iov. 53(N*u.�a1 ) <br /> VI.Tank Info Capacity in Total #of Manufacturer °: c o <br /> Gallons Gallons Units <br /> 'n' V ra 'l; <br /> New Tanks <br /> Existing Tanks o ,°'. .d, y ;g m <br /> a U in N A ii 0 il. <br /> Septic or Holding Tank 1585 — 1585 1 Wieser Concrete x <br /> Dosing Chamber -- x <br /> VII. fnavton <br /> ity Statement-I,the undersigned, s e respo ibility for installation the POWTS shown on the attached plans. <br /> Plumbrint) PI er Signa MP/MPRS Number Business Ph e <br /> R Daniels 007086 715-34 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 316 0,iren WI 872 <br /> VIII Court /De artment Use Off <br /> Permit Fee Date Issued IssuA t Signature <br /> Approved D Disapproved $ <br /> 3000 Q/,/l �t <br /> D Owner Given Reason for Denial a( U 07 <br /> IX.Conditions of ApprovaUReasons for Disapproval Lu <br /> f 2007 U <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 Ile rd jgA)4 du <br /> TT COUNTY <br /> ZONING <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />