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awr.mvn Caomy <br /> r1 ' Industry Services Division Rumen <br /> 4 p Z; 1400 E Washington Ave <br /> P t P.O. Box 7162 Sanit�Lary7 Pe�r�mit Number per be filled in by Ca.) <br /> %7iS k- Madison,WI 53707-7162 <br /> Sanitary Permit Application SwelfreasnuienNumne, <br /> In mwrdarce with SPS 38J21(2k Wil.Adm Cade,submission of Nis f m We eppmpomc govemmolnl unit <br /> is required poor to obtaining a sanitary permit Note:Appliemion fwrm for ddeowncd YDWI S are submitted <br /> Dere Dcpanment ofWcty and RofessiwW Swvim Persond is m atkm you pmvidc maybe used for secondary I'rojw Address(if diff nt Nan mailing address) <br /> u in acmrdmice with the Priv law s. 15. I m,Sun, 20666 Seem.Point of <br /> 1. Application Information-Please Print All Information <br /> Property()mar's Name P.]N <br /> David text Joan Andcnon 074)M-2-37.18-29-5 15-718-020000 <br /> Property Owner's Mailing Addrms Property Location <br /> 6577 McKinley St <br /> (in".I w <br /> City,Stale Zip Code Phone NumM `V.., '/.. SMion 29 <br /> Fridley ,MN 554324736 ]63-5]4-1349 (arcleom) <br /> 1'37N RINCo <br /> 11.Type of Building(cheek all that apply) Iota <br /> ® I or 2 Family Dwelling-Numher of nedrowns 9 Subdivision Name <br /> Sormse Point <br /> ❑ Publi✓Commercial-lescohe Use Hock N <br /> ❑Smte Owned-Inscribe Use ❑ City of <br /> CSM Number Cl villageuf <br /> Na ® Town of Trade lake <br /> III.Typeof Permit: Cloak onl one box on line A. Complete line B ifs liable <br /> A. [I New System ❑ Replamnent System ®TreumcnVHoldmg Tank Rplaorrom Only ❑Odic Modification to FAming Symno(explain) <br /> e. E] Permit Renewal ❑ Permit Revision El Choo of ❑Permit Transfer m New List Pmvious Permit Numbx mal Date IssuW <br /> Hefore Expiration Plumber Owaxa // 887 <br /> IV.Type of POWTS S stem/Com nentakvice: Check all that apply) <br /> ❑ Non-PressurvN In<irwmd ❑ Prcssuorad In(lrwmd ❑ AtGrade ❑Mourd>24 m.of suilede soil ❑ Mauna<N ire of wdxhle soil <br /> ® Holding Tank ❑(Aho Disposal Compenent(explain) ❑PmtrotmcntM icc(cxPluin) <br /> V.Dis ers.VF eatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Arm Require(sH Dispersal Aro Proposed(s0 Stern Elevation <br /> 450 Rateu s t) Na Na Na <br /> No <br /> VI.Tank Info Capacity in <br /> Galloon Toml N of E u <br /> Gallwn Unit Manufacturer u E - <br /> New Tanh Fxnffiy lr k y`U ✓� '� x U 6 <br /> Septic or Holding Tank 2000 2000 1 Wieser Concrete D 0 <br /> 11 ❑ <br /> Hosing Chsrnber 0 1 0 0 ❑ <br /> VII.Responsibility Statement- 1,the undersigned,assume rmpoosibli for imul (too of the P(1Wlti shown on the attached plans. <br /> Plumhtis Name(Pont) P bar" i ata MP/MPRS Nwnhc Roaress Plose Number <br /> Dayton Daniels 00]086 715-349-5533 <br /> Plumber's Address(Suet City,State,Lip Code) <br /> P.O.Box 326 Siren WI 54872 <br /> 01.Coun /De artment Use Only <br /> prove ❑ Disapproved Peron Fee Dme Issue Issuing t Sigsumre <br /> ❑Owns Given Reason fix Denial $3n15-vCo _ <br /> IX.Conditions of Approval/Reasom for Disapproval I LIU r <br /> fJG is EV LQ <br /> U <br /> JUL - 92014 <br /> AmismmmPktr p.mm.memrem.nd..hulnn me County nmy..pa, nosleanthan aInx Di <br /> WbMErr couNry <br /> ZONING <br />