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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 /> See reverse side for instructions for completing this application PO Box 7302 <br /> Madison,WI 53707-7302 <br /> Personal information you provide may 15. 04(1)(m)]be used for secondary purposes <br /> [Privacy Law,s. <br /> Department of i ommerce (Submit completed form to county if not <br /> state owned. <br /> Attach complete plans(to the count),copy only)for the s stem n paper not rexis than 8-1/2 x 1 I inches in size. U <br /> County State Sanitary Permit Nu er ❑Check if v n to revious ap lit ion State Plan 1.D.Number <br /> Burnett �p,$°�a,s-� 664369 <br /> I.Application Information - Please Print all Informat o Location: c <br /> Property Owner Name Property Location <br /> Karen & Keith Heyer pcl in NW1/4NE I/4,3 0 T38 ,N,Rl%46r)W <br /> Property Owners Mailing Address Lot Number Block Number <br /> 8710 Columbus Ave S na na <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Bloomington MN 55420 (952-851-4555 na <br /> II Type of Building: (check one) ❑City <br /> Q 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑ Public/Commercial(describe use): �JkTown of Wood River <br /> ❑ State-owned <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest RoadNelsonRd <br /> A) 1. ❑New System 2. 6 Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Only Existinp S stem 1prt of 042-2520-01 +E)e aI D <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground 6 Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V Dis ersaVTreatment Area Information: <br /> I.Design Flow(gpd) 2.DispersalArea 3.Dispersal Area 4.Soil Application S.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals/day/sq.R.) (Min./inch) Elevation <br /> 450 --� <br /> VI Tank Capacity in Total 4 of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> Holding tank 2000 -- 2000 1 Wieser Concrete ❑ ❑ ❑ ❑ <br /> VII Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumbers Name(print) 01cls Si natur (no st ps): MP/MPRS No. Business Phone Number <br /> Donald Daniels MP 330/221593 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 316 Siren WI 54872 <br /> VIII County/Department Use Only <br /> ❑Disapproved Sanitary Per Fee(Includes Groundwater Date ssued Issuing Age gnat s) <br /> pproved ❑Owner Given Initial Adverse Surcharge Fr � , <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R.07/00) <br />