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Generated by PDFKit.NET Evaluation <br /> COfnrtIBfCQ.W1.goV safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 BURNETT <br /> seonsin Madison,W153707-7162 Sanitary enniitNumberto e e m yCo.) <br /> i <br /> tDpertment of C mamerce �5 <br /> Sanitary Permit Application Stare Transaction rquoibe, W(�` <br /> In accordance with s.Comm 83.21(2),Wis.Adm.Code,submission of this form to the appropriate w <br /> governmental unit si required prior to obtaining a sanitary permit Note:Application forms for state-owned Project A i different than mailing a (1 <br /> POWTS are submitted to the Department of Commerce. Personal information you provide may be used for c� n <br /> seconds purposes in accordance with the Priv Law,s.15. 1 m,Stats. �1(— �- &4� 0 AUCIr PW <br /> 1. Application Information-Pleme Print A8 Information Parcel i' 020 1350&100 <br /> Property Owners Name <br /> 07-oto-z7'/0-/(o-07-S/$-5o <br /> Glen Armstrong �, sag I Property Location,. <br /> Property Owners Mailing Address Govt.Lot <br /> 7895 Blackstone Ave /., Y., section 7 <br /> City. tate rp o e one Number (circle one) <br /> Inver Grove Hts MN 55076 (612)239-2558 T 40 N; R 116 E r w <br /> It.Type of Building(check all that apply) Lot p �J Subdivision Name) rub <br /> I or 2 Family Dwelling-Number of Bedrooms 1 Block# Al2.QJA)t.5 *z4ow RI()u !lies <br /> ( Public/Commemial-Describe Use C City <br /> (� Stam Owned-Describe Use CSM Number C' Village Oakland <br /> (i Township o <br /> III.Type of Permit:-(Check only one box on line A. Complete out B Wa-ppUcable) <br /> (:New System ('Replacement System (1 TreatmenNHolding Tank Replacement Only Other Modificat m in Existing System <br /> B• I-Permit Renewal r Permit Revision F Change of Permit Transfer m New List Previous P Number and Date Issued <br /> Before Expiration Plumber Owner <br /> tV.Type of POWTS System: (Check all that apply) <br /> Non-Pressurized In-Ground r Pressurized In-Ground r At-Grade F Mound>24 in.of suitable soil <br /> Mound<24 in.of suitable soil <br /> r Holding Tank r Other Dispersal Componam(explain) F Pretreatment Device(explain) I'li <br /> V.Dlspersal/Trestment Area Information: <br /> Design Flow(gpd) Design Sod Application Rate(gpdsf) Dispersal Area Requited s(t) Dispersal Area Proposed(sf) nem Elevation <br /> 150.00 0.70 214.29 93,5 <br /> VI.Tank Info Capacity in Total Number Manufacturer <br /> Gallons Gallons of Units <br /> eW np u �j 3 'am <br /> Tank. I Taaka 0. U of LE (D y <br /> Sgsicortlolai.gTs.k 800 800 1 1 SkawPre-Cast X ! F r r r <br /> timig`barber r r r r <br /> VII.Responsibility Statement- 1,the undersigned,as/mmymee responsibility for installation of the POWTS shown on the a hed plam. <br /> Plumber's Name(Print) Plu is Sw/f/-' MP/MPRS Number Bus' ess Phone Number <br /> Ross Tollander 851954 (715)866-8070 <br /> Plumber's A Leet,City,State,Zip <br /> 27220 Jamison Rd.,Webster,WI 54893 <br /> VIII.County/Department Use Only <br /> Approved C_Disapproved Sanitary Permit Fce(includes Grouruhvater Zi-w <br /> ssued ]sa as t S' o Stamps) <br /> I—� Surcharge Feel // <br /> L I Owner Given Reason for Denial <br /> op <br /> � <br /> IX.Conditions of Approval/Reasom for Disapproval <br /> An.ch moplele pl..z(to the Cw.ty wly)for the system w Aper wt leu tha.612 z 11 wises'.du <br /> Click Ise@-609iMIbCAa1)KKItd4"0u09 <br />