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oommemef.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> i sco n s i n Madison,WI 53707-7162 Sanitary PermitNummber(to be filled in by Co.) <br /> I "rbnent of Commerce 1Sl/f/ 3 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21 2,W is.Adm.Code,submission of this forth to the �— <br /> O appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application fors for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary 23610 Sathre L-ane— <br /> purposes in accordance with the Privacy Law's. 15.04 I (m),Stats. <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Tony and Laura Doble 008-9050-03 100 <br /> Property Owner's Mailing Address Property Location <br /> 5453 32nd Ave. South <br /> Govt.Lot <br /> City,State Zip Code Phone Number Section 18 <br /> Minneapolis MIS 55417 612-724-6073 (circle one) <br /> T 38 N; R14EorW <br /> IL Type of Building(check all that apply) Lot# <br /> I or 2 Family Dwelling-Number of Bedrooms 2 20 Subdivision Name <br /> Block# Lund& Sathre Sub. <br /> ❑Public/Commercial-Describe Use 2 <br /> ❑ City of <br /> LJ State Owned-Describe Use CSM Number L1 Village of <br /> i Town of Dewey <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. L1 Permit Renewal ❑ Permit Revision 11 Change of Plumber <br /> ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that a 1 <br /> I 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.Dis ersaVrreatment Ares Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 300 .7 428.57 440 sq.it Based on Eisa of Cell#1=100.25' <br /> 20.0 x 22 Chambers Cell#2=99.07' <br /> Quick 4 Standard W <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Unitsi o'a <br /> New Tanks Existing Tanks '. c <br /> U rn m h u.Q C. <br /> Septic or Holding Tank 750 750 1 Wieser Concrete x <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's,Signature MP/MPRS Number Business Phone Number <br /> Robert Carlson / . t✓ �/ 135655 715-653-2500 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 3572115"Street Frederic WI 54837 <br /> VIII.County/Department Use Only <br /> 5r Approved ❑ Disapproved Permit Fee Date Issued Issuing store <br /> $ qq 97 <br /> ❑Owner Given Reason for Denial O�� M' ? 07 - <br /> tX.Conditions of Approval/Reasons for Disapproval <br /> Atbeh to complete plants for the system and submit to the County only on paper not les,than 8 t/2 x 11 inches in sire <br /> SBD-6398(R-01/07)Valid thru 01/09 <br />