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Safcry and Buildings Division Coumy --� <br /> 401 W. Wasbington Ave., P_0. Box 7162 Burnett <br /> )DelifarfmFentOnsinMadison,WI 5370 -7162Sanitary Permit Number(to be filled In by Ce) <br /> (WB)266-9151 �of Commerce <br /> Sanitary Permit Application S Plan LD.Number <br /> In accord with comm 83 21,lice,Atlm_Chu ,ppr ar al information you provide 1279164 <br /> may be used for secondary luroosea Privity Law.slat 04(Dom) Prover Address(if different Nan malar add... <br /> 1. Application hdorma/icn-Plea Print All Information <br /> 3891 County Rd A <br /> Properly Owner's Name Parcel p Lot q Black p <br /> Sohn& KatllTyp DanCC _ 012-4223-06-500 2 <br /> Polaris owner's Mallin,Address Property latcutioo <br /> 8564 Inwood Ave. So. _ Gov lot 2&3 u, SE A,section 23 <br /> City,Swk Zr Cude Phone Number <br /> T40 N; R.�S CC]arW® <br /> Cottage Grove, MN SSOl6 651 459-2283 <br /> H.Type of Building(check nil that apply) — <br /> SubdivisionNamc CSM Number <br /> ® 1 or 2 Family Owelling- Number of IInsranms 2 Vol I pg 151 <br /> 0 PublidCummeo en-Describe Use _ <br /> ❑Seen ownetl- Desuibe Use Deity OVlllage ®Tnwnelp,of Jackson <br /> III.Type of Permit (Check only one boa an line A. Complete line B if applicable) /-� <br /> A_ ® New System ❑ Replacemem System ❑ Trearmentnloldins Tank Replacement LJ Other Modlfa:lion to Existing System <br /> tiny <br /> B. Pvba,Renewal Permit Ravlsiun Change of L Permit Transfer in [is Previma Permit Number and Dam Issued <br /> Before Expiration Piumher New Owner <br /> IV.Type of POWYS System: (Check all that apply) <br /> 0 Non-Pressurized to Ground 0 Mound 224 in.of smarhde mil 0 shared < 24.,or sunable soil 0 Al-Grade 0 Single Pass Sand Filler <br /> OConsounfee Wetland 0 Pressurized In-Grouts ® Holding Tank 0 Peat Filler 0 Aaobie Treatment Unit 0 Recirculating Sand Filer <br /> mReclrculating Synthetic Media Hiro 0 Leaching Chamber 0 Drip Line 0 GravellessPipe 0 Other texplainp <br /> V. apetomlflYeat o it Area Information: -- <br /> Design Flow(gpm Design Soil Application Rabb i dsQ Di ,rl Are.Rvyuirai(at) Dispersal Area Proposed(s0 System Flevaron <br /> 300 <br /> V1.Tank Info Capacity in 'road Number Manufacturer P�grim Site Steel Plber Plastic <br /> G. rare Gallons of Units Concrete Caarru ued Glass <br /> New Exiatina <br /> Tviks laikn <br /> se,har rHolding There 10.T 2m] Wieser Concrete <br /> e_ x <br /> Pcrvbiu 1'rmMem Util - -- <br /> Marc Chembn <br /> VIL Responsibility Statement- 1,the nnderaigned,assume respomibBlty for mountain.or the PDWTS shown nn the atlnohed riuns. <br /> Plumber's Name(Print) Plumber's Sigmmre MP/dPRS Nunnhen Business Phone Number <br /> Richard O'Hare <br /> /!s _ _ 225920 715 634-6080 <br /> Plumber's Address(Street.Cr,State,Zip Code) <br /> 14346 W Slate Rd 77 Hayward, WI 54843 <br /> VIII. Chum /De war Use UN <br /> Approved ❑ DlnappmvW Sanitary <br /> Permit Fee(' dutlec Grmmdwalm llu.lsrval 1 A t Signa o stamps) <br /> Surcharge Fee) 3a�� I s s <br /> ❑ owrer Given Reaann for nenim <br /> IS <br /> Conditions of Approvap causons for Disapproval <br /> - <br /> Amok wmPtoo Plana(to the Conray anlal Inn the vPmm nn pxper sot Ieaa than 8112.It.thea in0h, <br /> SBD-6398 (R. 01/03) <br />