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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W WIhington Ave. <br /> PO Box 7302 <br /> Asconsin PerSee reverse side for instructions for completing this application <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not C)O <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> State Sanitary Permit Number heck if revision top ious application State Plan I.D.Number <br /> 45721 # <br /> County Burnett <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> Russ Schahn 1/4 1/4,S1 1 T401s15$'(br)w <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 245 Woodbridge Lane 48 na <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Lino Lakes MN 55014 ( ) -- Rainbow Pond add to W <br /> II.Type of Building: (check one) ❑city <br /> M I or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑Public/Commercial(describe use):_ rA Town of Jackson <br /> ❑ State-Owned <br /> Nearest Road �1 C� OM <br /> Pazcel Tax Numbe —952Ur(s)012Z11 5_8W <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. New 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> Won-pressurized In-ground ❑Mound ❑ Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment 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 /> 450 Required Proposed Rate(Galslday/sq.R.) (Min./inch) cell #1 98.00 ybr.it <br /> 750 808.60 .6 na c ll#2 97.40 100. <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks I Tanks <br /> 1000 -- 1000 1 Wieser Concrete » ° ° ° ° <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) mber's Si t,un.e,(�°stamps): MP/MPRS No. Business Phone Number <br /> Donald Daniels U MP 330/221593 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 316 Siren WI 54872 <br /> IX.County/Department Use Only <br /> �/ ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Iss ed Issuing a ignatur o stamps) <br /> I"Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> MA �I <br /> R 3 02004 <br /> 13URNETT <br /> ZONING <br /> SBD-6398(R.07/00) <br />