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Coumy <br /> / i °° Industry Services Division Burrett <br /> f , B 1400 E Washington Ave <br /> •al $ ` P.O. BOX 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 7 1 Madison,WI 53707-7162 /0 0 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2 Wis,Adm Code,submission of this form to the appropriate governmental unit eZ "Ie".) <br /> .) <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 Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04(l m,Stats. 28255 Tokash Rd <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> WILLIAM.&KATHRYN HOLMAN 07-028-240-14-24-5 05-006-015000 TAX#18520 <br /> Property Owner's Mailing Address Property Location <br /> 4117 ENSIGN AVE N <br /> Govt Lot 6 <br /> City,State Zip Code Phone Number '/4, 'Y., Section cR4 <br /> NEW HOPE,MN 55427 651 276 4102 (circle one) <br /> T40N R14EorW <br /> II.Type of Building(check all that apply) Lor# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number [I Village of <br /> R1 Town of 4 (W* <br /> III. a of Permit: (Check only one box on line A Complete line B if applicable) <br /> A- New System ® R{p�l`tracemem System ❑ Treatment/Holding Tank Replacemem Only El Other Modification to Existing System(explain) <br /> I—XV +b CC <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS S stem/Co 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) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation M...xl Isla_ <br /> 450 RaWgpdst) 643 <br /> .7 z 'x45' 2 DR.tS �4's.t5' <br /> VL Tank Info Capacity in <br /> 6 <br /> Gallons TOW #Of <br /> Gallons Units Manufacturer Upp d d <br /> New Tanks Extsung Tanks U rZ <br /> Septic or Holding Tank 700-300 1000 1 SKAW chambered ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber 600 600 ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement-I.the undersigned,assume responsibility for ippladiation of the POWTS shown on the attached plans. <br /> Plumber's Name( i &K SEPTIC & E = <br /> MP/MPRS Number Business Phone Number <br /> Mel Ferguson aVAIRON An,IM 11 NE MPRS 224879 <br /> Plumber's Address(Street, uKC" 54801 <br /> 715-635-7482 <br /> VIIL County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee ,,ry Date Issued Issuing Signature <br /> El Owner Given Reason for Denial $ 3-1 /✓ uY1'U.23. <br /> DC Conditions of Approval/Reasons for Disapproval <br /> jJoTL--: llfc TFc r-rr Mroldle Air,k sN (14 •�`'� /S 989.xrMV% . TAnMFrRN .rl r►wGc4fc, F �js D�� <br /> IS ~ &Q. or(,rt of � X16wt/Hrw.J IM <br /> ��(�� l J � IS a?ur.( fk �"rt�Fits+t �> <br /> AOwrw W /.o F+d 4 e 6iY oi{w u. 7%e L,[ �S x Via,f ednl.. fJ� lake 1, <br /> ^ Attach to complete plans for the system and sub tt nty�g1 Wogpape2UJ 8 111 inches in sin <br /> CS7�l� 7 7irf� 1 LUI (� <br /> BURNETT COUN'#Y o`t� Q <br /> ZONI!Nr <br />