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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 /> Vrisconsin see reverse side for instructions for completing this application PO Box 7302 <br /> Department of commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not !. <br /> Attach complete plans(to the county copy only)for the system,on pape not less than 8-1/2 x 11 inches in size. state owned.) ll <br /> Coun State nary Pe it Number lilt dri 11 4,794/ ❑C ck if revision to previo s application State Plan I.D.Number <br /> 2�- 300-7 � <br /> I.Application Information-Please Print all Information <br /> Property Owner Name Location: <br /> Raymond E. Johnson Property Location <br /> L2 <br /> Property Owner's Mailing Address 1/4 1/4,S 26 T 38,N,i 5X(or)W <br /> 11300 Hampshire Ave. South Lot Number Block Number <br /> 2 NA <br /> Bloomington, MN 55438 <br /> City,State Zip Code Phone Number <br /> Subdivision Name or CSM Number <br /> c ) <br /> II.Type of Building: (check one) NA Vol , 2 Pg. 225❑City <br /> )9< 1 or 2 Family Dwelling-No.of Bedrooms:�_ ❑Village <br /> ❑Public/Commercial(describe use):_ 0 Town of LaFol 1 ette <br /> ❑State-Owned <br /> Llrest Ro d013 l enter Lake Road <br /> cel Tax Number(s>014-2226-02 700 <br /> III.Type of Permit: (Check only one box on line A. Check box on line 5-if applicable) <br /> A) =NNew2. Replacement 3. ❑Replacement of 4. 5stem Tank Onl 6• ❑Addition to <br /> y Existing System <br /> atessued <br /> previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> Mon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> 11 At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/1 reatment 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) 1 95.70 Elevation <br /> 450 738 745 ,61 NA 2 95.30 98.70 <br /> VII.Tank 98.45 <br /> Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> 1000 --- 1000 Wieser Concret x ° ° ° ° <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) PI er's Signet e( stamps): MP/MPRS No. <br /> Dona 1 Dan i e l s Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) MP 330/221593 715-349-5533 <br /> 24056 St. Rd. 35 PO, Box 316 ' Siren, WI 54872 <br /> IX.County/Department Use Only <br /> ���� ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issui A t Signa o stamps) <br /> I11Approved ❑Owner Given Initial Adverse Surcharge Fee) �f I <br /> Determination I1�A� L3 bs <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />