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Safety&Buildings Division <br /> 201 W.Washington Ave. <br /> scons/n 5 Sanitary Permit Application 1Box 7302 <br /> In accord with Gomm 83.21,Wis.Adm. Code Madison,WI 53707-7302 <br /> Department of Commerce personal information you provide may be used for secondary purposes (Submit completed form to county if not <br /> [Privacy Law,s. 15.04(l)(m)] state owned.) <br /> Attach coat Teteplans to the county copy only)for the system,on papig not less than 8-1/2 x 11 inches in size. <br /> County BUYGIett State Sanitary Permit Number ❑Ch iWsio Ito previo application State Plan I.D.Number <br /> L Application Information-Please Print Al Information v7 5 Location: (� <br /> Property Owner Name Properly Location <br /> Charles & Gail M Hanson 7 40 1 <br /> 1/4 1/4,S T ,N,R , rj <br /> Properly Owner's Mailing Address Lot Number Block Number <br /> 1099 LawnVielf Ave 2 6pv t�_,C err I na <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> St Paul :. MN 55126 ( ) CSM Vol 17 Pg 116 & 117 <br /> II Type of Building: (check one) city <br /> LY 1 or 2 Family Dwelling—No.of Bedrooms: 3village JaCksOri <br /> M Town of <br /> ❑ Public/Commercial(describe use): <br /> ❑ State-owned <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> Ham Ridge Trail <br /> A) 1. ID New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to P !VT!M) 500 <br /> System Tank OnlyExistingSystem B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> ISNon-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.DispersalArea 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(GalsJday/sq.ft.) (Min./inch) Elevation <br /> 450 375 377 .7 na 96.50 99.30 <br /> VI 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 Tanks <br /> 1000 -- 1000 1 Wieser Concrete <br /> VII Responsibility Statement <br /> I,the undersigned,assume res ±bili for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) PI bee Signature(no stamps): MP/MPRS No. Business Phone Number <br /> Donald Daniels ZZ7 1 MP 300/2.21593 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 /> K/ ❑Disapproved Sanitary Pe= Fee(Includes Groundwater Date Issued Issuing S'yaturcm <br /> )�f Approved ❑Owner Given Initial Adverse Surcharge Fee) > C <br /> aaa <br /> Determination ( ✓' /6'//` <br /> IX.Conditions of Approval/Reasons for Disapproval: <br />