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LL DILHR STATE OF WISCONSIN DILHR <br /> PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING BUILDINGS <br /> 201 E.Washington Avenue,Rm 178 <br /> PLAN APPROVAL APPLICATION P.O.Box 7969,Madison,WI 53707 <br /> 608.2663815 <br /> INSTRUCTIONS: Please fill in all applicable data and submit this form with plans. Plans will not be reviewed until all fees are received. <br /> The back side of this form describes required plan information. Plumbing codes can be purchased from the Department of Administration, <br /> Document Sales,202 South Thornton Ave., Madison,Wisconsin 53703,Telephone (608)266-3358. <br /> 1. PROJECT INFORMATION (Type or print clearly) <br /> Name of Submitting Party (Plans returned to same) Project Name <br /> Brauer & Associates, Ltd. Herzel Camp--Haks <br /> Street&No. Project Location -Street&No.or Legal Description <br /> 7901 Flying Cloud Drive Section 33 T40N R16W <br /> City State Zip Code ❑ City County <br /> Eden Prairie, MN 55344 1:1 Village Burnett <br /> IM Town <br /> Designer Telephone No. (Include Area Code) <br /> Warren White 715/483-3010 <br /> 2. THIS APPLICATION IS FOR A: <br /> ® New Mound System (3) ❑ Holding Tank (2) <br /> IN New Pressurized System on site not suitable ® Petition For Modification (6) <br /> for conventional (3) ❑ Replacement Mound (4) <br /> ❑ Replacement Pressurized System on site not ❑ System in Fill (1) <br /> suitable for conventional (4) ❑ System in Flood Fringe (11 <br /> ❑ Pressurized System on site suitable for ❑ Groundwater Monitoring (7) <br /> conventional (1) <br /> ❑ Conventional System -Public Building (1) <br /> 3. FEE COMPUTATIONS (Include existing tanks) 4. FEE SUBMITTED FOR OFFICE USE <br /> 3a. 750 - 1,500 gallon septic tank - 30.00 4a. 30.00 <br /> 3b. 1,501 - 2,500 gallon septic tank - 40.00 41b. 120.00 <br /> 3c. 2,501 - 4,000 gallon septic tank - 55.00 4c. <br /> 3d. 4,001 - 8,000 gallon septic tank - 70.00 4d. <br /> 3e. 8,001 - 12,000 gallon septic tank - 85.00 4e. <br /> 3f. Over 12,000 gallon septic tank - 100.00 4f. <br /> 3g. 500- 1,000 gallon pump chamber - 30.00 4g. 30.00 <br /> 3h. 1,001 - 2,000 gallon pump chamber - 35.00 4h. <br /> 3i. 2,001 - 4,000 gallon pump chamber - 50.00 4i. <br /> 3j. 4,001 - 8,000 gallon pump chamber - 65.00 4j. <br /> 3k. 8,001 - 12,000 gallon pump chamber - 80.00 4k. <br /> 31. Over 12,000 gallon pump chamber - 95.00 41. <br /> 3m. 500 - 5,000 gallon holding tank - 30.00 4m. <br /> 3n. 5,001 - 10,000 gallon holding tank - 40.00 4n. <br /> 3o. Over 10,000 gallon holding tank - 50.00 4o. <br /> 3p. Groundwater Monitoring - 32.00 4p. 32.00 <br /> Subtotal <br /> 3q. Priority plan review: (walk through) 4q. <br /> Submittal of plans in person, <br /> by appointment, with double fee <br /> 3r. Petition for Modification <br /> Setback - 20.00 4r. Z� <br /> Site evaluation - 50.00 <br /> Total Fees" <br /> COMMENTS: <br /> DI LHR SBD6748 (R.5/821 -OVER- <br />