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Generated by PDFKit.NET Evaluation I <br /> oommeree.wi.gov Safety and Buildings Division aunty <br /> ■ 201 W.Washington Wl Ave.,0 P.O.Box 7162 <br /> BURNETT <br /> � mMadison,WI 53707-7162 aaa?ry,Te—mutr(to ro led m y o.) <br /> Sanitary Permit Application Stn- Transactits Number Q j <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this fore to the appropriate <br /> governmental unit is required prior to obtaining a sanitary permit. Note:Application forms for state-owned Pro)ect A ressdifferent than mailing ss <br /> POWTS are submitted isi to the Depante with t of Commerce. Personal information you provide may be used for ^ _ ^ �^ <br /> seconds a sea in accordance with the Priv Law,s.15.04(l m,Stats. Dlf rim` lJ I `•vr L <br /> 1. Application Information-Please Print All Information •gQ•gpa <br /> naris ame /�j O <br /> BaryaryPropeS Swenson 7' <br /> Property Locatio 5.��1 _ 021.4 ' kJ��Z <br /> roperty o sat urg A 6ese.-Eat <br /> _ <br /> 8455 Manning Ave n NW i,, N %, section 25 <br /> nye State tp o one Num (circle one) <br /> stillwater40 6 E ur W <br /> MN 55082 (651)430-1232 T N; R � <br /> H.Type of Building(check all that apply) Lot# Subdivision Nam <br /> (a 1 or 2 Family Dwelling-Number of Bedrooms 3 <br /> Block# <br /> (7 Public/Commercial-Describe Use City <br /> (" State Owned-Describe Use CSM Number Village Oakland <br /> (i Towmhipo <br /> III.Typeof Permit: (Check only om box en Bne A. Complete tine B if applicable) <br /> To New System (^Replacement System (1 Treatment/Holding Tank Replacement Only ('Other Modifies ion to Existing System <br /> B. r Permit Renewal r Petmit Revision r Change of r Permit Transfer to New List Previous Penn t Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IIV.Type of POWTS System: (Check all that apply) <br /> Non-Pressurized In-Ground r Pressurized In-Ground (— At-Grade <br /> r Mound>24 in of suitable soil F Mored 124 in.of suitable sail <br /> r Holding f mk r Other Disposal Component(explain) <br /> F Pretreatment Device(explain) <br /> V.DispersaVrreetment Area Information: <br /> Design Flow(gpd) Design It Application Rare(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) ystem Elevation <br /> 450.00 0.70 642.86 651.60 1. (®5 <br /> VI.Tank Info Capacity in Total Number Manufacturer <br /> Gallons Gallons Of Units <br /> _ U <br /> CW Zwas V F U U yW <br /> Tanks Tedu a tj vi N ia. C7 <br /> d a <br /> Septic or Holding Tank /000 1d 00 1 5 k,J•V,,,� <br /> EX F F r r <br /> D.smg Char r r r r r <br /> VII.Responsibility Statement-1,the undersigned,ass■me responsibility for installation of the POWTS she"on the sits,bed plum. <br /> Plumber's Name(Print) Plup�er's� MP/MPRS Number Bus' esu Phone Number <br /> Ross Tollander /(/Yj 851954 (86 )807-0 <br /> Plumber's A (Street,City,State,Zip Code) <br /> 27220 Jamison Rd,Webster,WI 54893 <br /> VII County/Department Use Only <br /> Approved (� Disapproved Sanitary Permit Fee(includes Groundwoter Doe Issued Wit t Sign Stamps) <br /> Surchoge Fee) n 7 <br /> L_ Owner Given Reason for Denial d <br /> M Conditions of Appreval/Rasees for Disapproval <br /> 61AY i? 2007 <br /> BURNE COUNTY <br /> A Wd rn■plete Olds(to lac Caaety Daly)far ry■es a•paper set Iw IYaa 3112 x 11 hada w <br /> Click Nwa-6093011icDaAB4)RA611446,T01/09 <br />