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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> e Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> t:1sc0m;;sLw'!gn0v <br /> epartmS <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) 9..� <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary 29063 Bluff Lake Rd. J <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Slats. <br /> 1. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# �v <br /> Mike Sarenpa / n 0364409-04100 <br /> Property Owner's Mailing Address W b Property Location <br /> P.O.Box 288 Parcel in <br /> Govt.Lot 6 <br /> City,State Zip Code Phone Number Section 9 <br /> Hinckley MN 55037 612-390-1735 (circle one) <br /> T 40 N; R17EorW <br /> II.Type of Building(check all that apply) Lot# <br /> 111 or 2 Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> ❑Town of Union <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. El Permit Renewal ❑ Permit Revision El Change of Plumber El Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/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 Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 .5 900 900 sq.ft.Based on Eisa of Cell#1 =101.00'Cell#3= <br /> 20.0 x 45 Chambers Cell#2=98.40' 98.00' <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units U$ <br /> New Tanks Existing Tanks <br /> U iq <br /> Septic m Holding Tank 1000 1000 1 Wieser Concrete x <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility f nstanstion of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber' at MP/MPRS Number Business Phone Number <br /> Robert Carlson � 135655 715-653-2500 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 3572115th Street Frederic WI 54837 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved PermitFeeDaze Issued Issuing Ignature <br /> ❑Owner Given Reason for Denial O Jl/1P 13,NN• Q <br /> M.Conditions of Approval/Reasons for Disapproval <br /> Attach m complete phos for the system and submit to the County only on paper not leas than 8 M x 11 inches in size <br /> SBD-6398(R 01/07)Valid thru 0I/09 <br />