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osr.arumr County <br /> Safety and Buildings Division CmmtyBurnett <br /> p �{ 201 W.Washington Ave., P.O.Box 7162 Sooner,Permit Number(to be filled in by Ci,") <br /> S <br /> p8, _ Madison,W153707-7162 <br /> `k 55899 J,l <br /> Sanitary Permit Application Stam Trmsaction Number <br /> In accoNance with S'S 3x3 21(2),Wis.Adm.Coda submission of Nis form to the appropriate gtwernmrnW unit Av") <br /> is"unedpourtoobtainingaaanimrypemiit. NoteRojco Addmss(ifdi HeratNmmailingaddrtss) <br /> the Ucpanrmnt of Safety and Itofessiomd Servics. Personal information you provide may be used for scmnday <br /> in accorihme wins the T'n,tay Law,s. 15 M(1-0.Sims. 9483 Dunham Lake Drive <br /> 1. Application Information-Please Print All Information <br /> Pro,sn,Owner's Name I I pace]a <br /> Roger Jr.and Renee Ekstrand 3�a 07-006-2-38-17-21-505-005-024000 <br /> Property Owners Mailing Addpss TTTT���I propertylumen partNio <br /> P.O. Box 8 <br /> Govt.let 5.6 <br /> City,Store Zip Cale Phone Number _ '/,, S W '/., Section 21 <br /> Dickinson ND 58602 605203-1614 (60cone) <br /> IL Type of Building(check all that apply) let a '1'38 N; R 17 F. W <br /> ® 1 ort Family Dwelling-Number of Bedmoms 2 U-Mapa 1553 Subdivision Name <br /> Block a <br /> ❑PublirXmirom cial-Describe Uu <br /> ❑Cit,of <br /> ❑St Cwro,d-Dcsenbe Use CSM Number ❑ Village of <br /> 18 Town of Daniels <br /> 111.Type of Permit: (Check only one box on line A. Complete line B ifapplicable) <br /> A, Cl New System IS Replacement System ❑l'tamsenN lolding"fmik Replacement Onh ❑Other Modification to Existing SYVM(explain) <br /> B. ❑ pmnit Racwal ❑ permit Revision ❑Change of Plumber ❑Pcmtit Iransferm New List Previous Permit Number atd Elite Issued <br /> Before Fapira ion puna <br /> IV.Type of POWTS S stem/Com onent/Uevice: Cheek ell theta I <br /> to Non-Prcsnutlacd]n-Ground 131rt.sunrcdln-Ground ❑ At{krade ❑ Moun1>24in.ofmitablesoil ❑Mound<24iaofsultablesoil <br /> O l lolding Tank ❑(Ther Dispersal Component(explain) ❑Premearnrtrit Devi«(explain) <br /> V.Dis rsaVTreatme.t Area Information: <br /> Ik.ign now(end) Deign Soil App]icatim Rme(gshf, Irspersal Ara Requited(sn Dispersal Ara FmµuW(so Syzem Elevation <br /> 300 .45 666.67 EISA of 700 Cell 1 94.75'cc112=93.60' <br /> VL Tank Info Capacity in 'Total anf6W�iuer <br /> ufamurtr <br /> Galnns Gallons Units E <br /> New raNs fxistinB Tonka " N � au` � <br /> �U uU a <br /> % roc m Holding rank 1000 1000 X oncrete X <br /> froi ,C Ixr 600 600 ation X <br /> VII.Responsibility Statement- 1.the imifirmigned,me res poavbility rimuP(IW'I <br /> instillation ofthe S shown on the attached plana <br /> Plu (Prot)r's Name(Prot) <br /> P ber's:iMI'IMPRS Number Business Phone Number <br /> Dayton Daniels - 007086 715349-5533 <br /> Numkr s Address(Stasel City,State Gip Code) <br /> P.O.Box 326 Siren W 154872 <br /> V�-.I✓II.Court /De artment Ilse Only <br /> o] A,wwvcd ❑DisapprovN Permit Fec Te" fcsued Issuing $ipPatum <br /> ❑Owner Given Remora for Denial 5 3r�5%y „ tG�/�j <br /> IX.Conditions of ApprovaVRiesons for Disapproval <br /> ,ameb m rvmpnle perm re.rhe mtem.m mbmir to rte cwnry Deft oa PKr wt Ion rlar a to a t t ixbe roto, <br />