Laserfiche WebLink
commeree.wl.gov Safety and Buildings Division County <br /> i 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> �scon in Madison,W1 53707-7162 Sanitary Permit Number(to be filledCo in I, <br /> Department of Commmerce Sz 1 I 2 9 <br /> Sanitary Permit Application State Transactrn Number <br /> In accordance Leith s.Comm.83 1592131 <br /> Leith <br /> Wis.Adm.Code,submission of this form to the appropriate goventmental <br /> unit is required prior to obtaining a sanitary permit. Note_ Application forms for sette-owned POWTS arc --�1�'1V1 <br /> submitted to the Department of Commerce- Personal information you provide may be used for eewndary Project Address(it different than mailing addrese) f <br /> ur oses in accordance with the PrivacyLaw,s. 15.04 I m),Stats. 3688 South Shore Rd �� <br /> 1. Application Information—Please Print All Information <br /> Property Owner's Name # <br /> James&Stacie Shandorf l_ (� �( Parcel Parcel35-OS 900 <br /> Property Owner's Mailing Address Property Location <br /> 11539 Ashley Court <br /> Govt Lot 5 <br /> CityState Zip Code Phone Number Secuon 35 <br /> Inver Grove,MN 55077 651-387-0376 (Check Ona) '. <br /> 11.Type of Building(check all that apply) Lot# T 40 N. R 15 ❑E 0 W <br /> ❑✓ I m2Family Dwelling—NumberofBedrooms 3 3 Subdivismn N_amc <br /> ❑ <br /> Public/Commercial—DescribeUse Block a CSM Vol.1 Pg.161 <br /> City of <br /> ❑State Owned—Describe Use CSMNumber Village of <br /> V , � ❑✓ 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 ❑✓ TreatmenUHulding Tank Replacement Only ❑ Other Modification to Existing.SNstan(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 /> Expiration <br /> IV.T e of POWTS S stem/Com onent/Deviee: Check all that a I <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑ Mound>24 inofeuitable soil El Word<24 in.of suiwble soil <br /> ❑✓ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment De,ice(explain) <br /> V. Dispersal/Treatment Area Information: <br /> es'ign Flow(gpd) Design Soil Application Rate(gpdsq Dispersal Area Required(st) Dispersal Area Proposed(s) SN''t"a Llevalion <br /> 300 GPD NA NA <br /> VI.Tank Info Capacity in Total #of Manufacturer Material <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks :1 <br /> Sgnic or Holding Tank Holding Tank 20000J1 Wieser WLP2000-MR Prefab Concrete <br /> Dosing Chamber <br /> VI 1. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PI I b ign. I MP/MPRs Number Business Phone Number <br /> Dayton R.Daniels _ / - 11600 715-349-5533 <br /> Plumher's Address(Street,City,State,Zip Code) <br /> 24056 St.Rd.35 P.O.Box 326 Siren,WI 54872 <br /> VIII.County/De artment Use Onl <br /> pproved _ Disapproved Permit Fee Date Issued Issuing A gnature <br /> _Owner Given Reason for Denial $ 350" <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> .1/o TE: Af0 $vr><d6� d&41 IS 1,l r,- dK OA.S16c sot( ar,sarI46r,t+C_ R. <br /> Attach to complete plans for the system and submit to the County only on paper not less then a ux x I I iochc.is srsc <br /> SBD-6398(R.01/07)Valid thou 01/09 <br />