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commerceml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> i sc o n s i n Madison,WI 53707 71 62 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce / 07 <br /> Sanitary Permit ApplicationeTransacttiionNuQmber <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental Gvd+4`� I�V I Cad --�- <br /> unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary ag � <br /> eerpaloI(`�Q <br /> purposes in accordance with the PrivacyLaw,s. 15.04 1 I <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name /,glia (vlicollcher_ Parcel# b /h1/,7'�nao <br /> Scott Schulze80y Maple56r.ef. ) C.o� <br /> l u5 07-012-2-40-15-10-5 15-128-280000 <br /> Property Owner's Mailing Address Cpt1011twa i=611S, Wr 54879 Property Location <br /> 14 East Gilfillan Rd. <br /> Govt.Lot <br /> City,State Zip Code Phone Number _'/,, '/., Section 100 <br /> North Oak MN 55127 651-235-0178 /,47ctr�cIc one) <br /> T40N; R15-Eo W / <br /> IL Type of Building(check all that apply) Lot# ✓✓✓' <br /> ■] or 2 Family Dwelling-Number of Bedrooms 3 279 Subdivision Name <br /> Block# Deer Path Add.To Voyager Village <br /> D Public/Commercial-Describe Use <br /> ❑ City of <br /> D State Owned-Describe Use CSM Number D Village of <br /> ®Town of Jackson <br /> 111.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A' 2 New System D Replacement System D Treatment/Holding Tank Replacement Only D Other Modification to Existing System(explain) <br /> ) <br /> B. D Permit Renewal D Permit Revision D Change of Plumber D Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POINTS S stem/Com onent/Device: Check all that apply) <br /> ®Non-Pressurized In-Ground D Pressurized In-Ground D At-Grade D Mound>24 in.of suitable soil D Mound<24 in.of suitable soil <br /> D Holding Tank D Other Dispersal Component(explain) D PreVeatment Device(explain) <br /> V.Dispersal/Treatment Area Information: Quick 4 Standard-W Low Pro Chambers Eisa Rating of 20.00 sq.ft. <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 .7 642.85 680 94.83-92.90 <br /> Vl.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o'er <br /> New Tanks Existing Tanks <br /> cS; U in rn w O P. <br /> Septic or Holding Tank 1000 1000 1 Wieser Concrete X <br /> Dosing Chamber 500 C bfnpble $r/,AC_ <br /> V11.Responsibility Statement- 1,the undersignA assume responsibility for installation of the POWTS shown on the attached plana <br /> Plumber's Name(Print) P er's St store MP/MPRS Number Business Phone Number <br /> Dayton Daniels <br /> t MPRS#007086 715349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> P.O.Box 326 Siren WI 54872 <br /> VIIJ6 County/Department Use Only <br /> Approved D Disapproved Permit Fee Date Issued Issuin at Signature <br /> $ <br /> D 3 <br /> AL <br /> 2,Jr�or I' <br /> Owner Given Reason for Denial �O <br /> IX.Conditions of Approval/Reasons for Disapproval p <br /> more: net/IseO T. doAd Con„ Eraaa( at? c' !fa'brvx. <br /> v <br /> Attach to romplete plans for the system and submit to the County only on paper not less than 8 in all inches in size <br /> SBD-6398(R.02/09)Valid than 02/11 <br />