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® <br />Av <br />Industry Services Division <br />1400 E Washington Ave <br />P.O. Box 7162 <br />Madison, WI 53707-7162 <br />county <br />"X $ ,S' 7y/ <br />Sanitary Permit Number (to be filled in by Co.) <br />t% IOS <br />j! v' <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />*14 <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />Project Address (if different than mailing address) <br />purposes in accordance with the Privacy Law, s. 15.04(l m , Stats. <br />,o <br />L Application Information —Please Print All Information <br />Property Owner's Name <br />Parcel # <br />JEROME C & ALVERDA R SIMCOE <br />07-024-2-39-14-10-5 05-004-020000 <br />TAX#15741 <br />Property Owner's Mailing Address <br />Property Location <br />6040 CREEKVIEW LN N <br />Govt. Lot 4,1.9 ACRES <br />City, State <br />Zip Code <br />Phone Number <br />1/4, '/4, Section 10 <br />BROOKLYN PARK, MN <br />55443 <br />763. 537.1492 <br />(circle one) <br />T39N R14EorW <br />II. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />® 1 or 2 Family Dwelling - Number of Bedrooms Z. <br />❑ Public/Commercial - Describe Use <br />Block a <br />❑ City of <br />❑ Village of <br />® Town of RUSK <br />❑ State Owned - Describe Use _ _ _ <br />CSM Number <br />V2 P46 <br />III. <br />e of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />❑ Replacement System <br />® Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B <br />El Permit Renewal <br />Before Expiration <br />❑Permit Revision <br />El Change of <br />Plumber <br />❑ Permit Transfer to New <br />Owner <br />List Previous Permit Number and Date Issued <br />IV. <br />Type of POWTS S stem/Com nent/Device: (Check all that apply) <br />® Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application <br />Dispersal Area Required (si) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />300 <br />Rate(gpdsf) <br />429 <br />STEEL TANK <br />EXISTING @ 93.95' <br />.7 <br />REPLACEMENT <br />VL Tank Info <br />Capacity in <br />Gallons <br />Total <br />dons <br /># Of <br />Units Manufacturer 4 c <br />U A <br />P <br />New Tanks Existing Tanks <br />Septic or Holding Tank800 <br />800 <br />SKAW ® ❑ <br />❑ ❑ ❑ <br />Dosing Chamber I <br />I El I ❑ <br />❑ ❑ ❑ <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for iqqaHation of the POWTS shown on the attached plans. <br />Plumber's Name ( CC�'^ cy^ �j fig.!n" MP/MPRS Number Business Phone Number <br />�n� t�+ <br />Mel Fer on d s7G lI C/�V <br />MPRS 224879 <br />Plumber's Address (OR 0mvii8ol <br />5-7482 <br />vin Court /De artment Use Only <br />Approved <br />❑ Disapproved <br />❑ Owner Given Reason for Denial <br />Permit Feeoo <br />s 3 7,1', <br />Date Issued <br />7 /Q "1 <br />Issuing Agent Signature <br />DL Conditions of Approval/Reasons for Disapproval <br />--J�4w APPROVED . ECE�VE nn <br />Attach to complete plans for the system and submk to the County only on paper not less than 81 � 11'14ches <br />16 2018 U <br />BURNED" COUNTY <br />7nl IMI'r <br />