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cornmerce.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> Ii sco n i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> c apartment of CornMem -,:;3 1�A <br /> v Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),W is.Adm.Code,submission of this form to the appropriate governmental <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 5579 Ham Ridge Trail <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Robert and Carolyn Tilton / 3 0124207-09520 <br /> Property Owner's Mailing Address (. Property Location <br /> 4813 School Road <br /> Govt.Lot 9 <br /> City,State Zip Code Phone Number Section 7 <br /> Edina MN 55424 952-920-0356 (circle one) <br /> T 40 N; R15EorW <br /> IL Type of Building(check all that apply) Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms 3 2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> L1 State Owned-Describe UseCSM Number 11 Village of <br /> Vol.15 Pg.101 <br /> Town of Jackson <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> `t' ❑New System ®Replacement System ❑Treatment/Holding Tank Replacement Only other Modification to Existing System(explain) <br /> Addition of an Effluent Filter <br /> B. ❑ Permit Renewal 11 El Revision ❑ Change of Plumber- Permit Transfer to New rst Previo Permit Number an Is/su/ed <br /> Before Expiration Owner #1 168 1-22-95 p7 µgoZ� <br /> IV.Type of POWTS S stem/Coro oneut/Device: Check all that apply) <br /> 0 Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Bolding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: Infiltrator Quick 4 Standard-W Leaching Chambers <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 .7 643 680 sq.f.Based on Eisa of Cell#1=92.75' <br /> 20.0 a 34 Chambers Cell#2=91.35' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a <br /> New Tanks Existing Tanks A 2 rd <br /> U <br /> Septic or Bolding Tank 1000 1000 1 Skaw Concrete x <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) P bet' Signer n MP/MPRS Number Business Phone Number <br /> Dayton Daniels /{,�/�h� ;,D MP#007086 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) "`"'"`fff��� ��'!�� <br /> P.O.Box 316 Siren WI 54872 <br /> VIIL County/Department Use Only <br /> ❑ Approved ❑ Disapproved Permit Fee Date Issued Issuing ignature <br /> $ <br /> ❑Owner Given Reason for Denial <br /> LY.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than a In x 11 inches in sin <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />