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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> 84sconsin Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> De artment of Commerce (608)266-3151 4-78, 89 <br /> Sanitary Permit Application Sate plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy law,sl5.04(1 xm) Project Address(if different than mailing address) <br /> ba 10 <br /> 1. Application Information-Please Print AB Information Minnow Lake Rd <br /> Property Owner's Name panel# ��Lootnt# Block# <br /> Henry Michaels <br /> Property Owner's Mailing Address Property Location <br /> 14 Glenside Terr SC SE <br /> City.State Zip Cede Phone Number — /., _Y.. Seclian 2 <br /> Mount Claire NJ 07043 973-509-2232 T 40 N: R Jeimlf one) <br /> If.Type of Building(check all that apply) ✓ <br /> ©I or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name CSM Number <br /> Public/Commerrid-Describe Use r� _ <br /> ❑State Owned-Describe Use ❑Chy QVillage 0rownship of Oakland <br /> III.Type of Permit: (Check only one boa on Hue A. Complete line B if applicable) <br /> A. ❑Replacement System 0 New System ep ys ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Tmmfer to New List Previous Permit Number and Date Issued <br /> Before Expiratiro Plumber Owma <br /> IV.Type of POINTS System: Check all that apply) <br /> 0 Non-Pressuriced in-Ground ❑Mound>24 in.ofsuitable soil 13 Mound 124 in.ofsuitable soil ❑AK)mde ❑Single Pass Sand Filter ❑ <br /> C'onstmeted Weiland ❑ Pressurized In-Ground ❑Ilolding Tank E3 Prat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Rccirculatin Synthetic Melia Filter ❑Leaching Chamber ❑Drip Linc 17 Grovel-less Pipe ❑(Aher(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Deign Flow(gpol Design Soil Application Ralctgpdsf) Dispersal Arm Required(sq 11 Dispersal Arm Proposed(sf) System Elevation <br /> 1,450 450 —I (Qy3 N Cl b'1 k o I <br /> VI.Tank Info Capacity in TotalNumber Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New B ming <br /> Tanks Tasks <br /> Septic or Nokbiw`,ank 1000 1000 1 Wieser x <br /> Aerobic T¢armcaa Unit <br /> Dosing Clamber <br /> VII.ResponsibWty Statement- 1,the undersigned,sas®e respyluilhility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) MP/MPRS Number Business Phone Number <br /> PI r' Si male <br /> Clayton Staines 230725 715-822-3215 <br /> Plumber's Address(Street,City,State,Zip COF <br /> P O Box 505 Cumberland WI 54829 <br /> VIII.County/Department Use Only 117 <br /> Approved Disapproved Sanitary Permit Fee(includes;Groundwater Date Issuer) Is, brcnt Sig - re(No Stamps) <br /> surcharge <br /> Fce) �h / x <br /> ❑Owner Given Reason for Demiel 2 �rA /1((��T 05 <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> Attach complete pha,(to the County only)for tae system oa paper or tons than 8112 s it Inch.lotion, <br /> SBD-6398 (R. 01/03) <br />