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X. a 'n .G. i'.0 <br /> ` isconsin �'L!l. �.❑ �`i �) - - ) T.:] r �.";I:�./W l' Ci '.0 dt III�C'❑ '� l �.' <br /> ment of Commerce <br /> 1604)2tm-'II <br /> Departll <br /> Sanitary Permit Application .. State Plan I.D.Number <br /> In acm cord with Com93.21,Wu.Adm.Code,personal information yoprovide <br /> may be used for secondary purposes Privacy Law,sl5.04(lxm) Project Address(if different than mailing address) <br /> I. Application Information—Please Print A I Information C04 fn- <br /> Property Owaer's Name VParcel# Lot# Block# <br /> , f" ll't_ s OA- 3101-01-6)0b lJ <br /> Pry,1Owesces3 /fig C J� �� Property Location <br /> �w 5 / <br /> -�IAJ Y., Y., Samoa <br /> City,State I Zip ,7 Color� Phone Number <br /> S 96¢,V Q f J�-1- 7 O I T N, R tcircle one) <br /> II.Ty&of Building(chleck all that apply) <br /> Subdivision Name CSM Number <br /> Ja 1 or 2 Family Dwelling-Number of Bedrooms + <br /> Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use QCity_Qvillage aowmship of .r S <br /> zK- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New System 2�Replacement System ❑Treatment(Holding Tank Replacement Only ❑Other Modification to Existing System <br /> S. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> M Type of POWTS System: Check all that ap 1 <br /> Q'Ran—Pressurized in-Ground ❑Mound>24 in.of suitable soil 0 Mound<24 in.of suitable and ❑At-Grade ❑Single Pass Sand Filter ❑ <br /> constructed Wetland ❑pressurized In-Ground ❑Holding Tank ❑Pest Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Symbetic Media Filter ❑Leaching Chamber 13 Drip Cine 0 Gravel-less Pipe 0 Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Ratelgpdsf) Dispersal Area Required(sf) Dispersal Arm Proposed(sf) System Elevation <br /> 00 , 7 1-1Z aV3Z -?-fs <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic err Holding Tank 7S0 <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-L,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Nam ) P SiW/MPRS iVum�ber <br /> (D Business Phone Number <br /> ��c�lN✓ x Vn( 9 7/5 o�3S 62 <br /> Plumber's Address(Street,City,State,Zip e) <br /> W R5o 2 'l7oc.K 4 && Road , t-5Poo)1W Gtr► S49of <br /> nun /De rtment Use Only z� <br /> Approved ❑Disapproved Smiury Permit Fee(includes Groundwater Date Issued b7s ' t Si o Stamps) <br /> Surcharge Fee) 25„I� /) 2G ,/ <br /> ❑ Owner Given Reason for Demist G`f' <br /> IX.Conditions of Approval/Rasons for Disapproval <br /> OCT 2004 <br /> Attach complete plain(to the Coanty only)for the system on paper not less than ai/2 m I1 ineho in s <br /> NUMNETT COUNTY <br /> ZONING <br /> SBD-6394 (R. 01/03) <br />