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oeeN"t�evr County <br /> Industry Services Division BUNT <br /> ` 1400 E Washington Ave <br /> P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> (►$ <br /> Madison,WI 53707-7162 592 <br /> I <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application fors for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Stats. 6158 LANDING RD WEBSTER 54893 <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> MICHAEL&MARY GAIDA 07-020-240-16-36-5 15-095-015000 <br /> Property Owner's Mailing Address Property Location <br /> 676 HEINEL DRIVE <br /> Govt.Lot <br /> City,State Zip Code Phone Number V., /4, Section 36 <br /> ROSEVILLE,MN 55113 (612)244-0124 (circle one) <br /> T36N; R16WEorW <br /> IL Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms 'j 5 Subdivision Name <br /> CONNOWS LAKE ADD <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> ® Town of OAKLAND <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. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System/Component/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 Dispersal Area Required(s I Dispersal Area Proposed(st) System Elevation <br /> 450 Rate(gpdst) N/A <br /> VI.Tank Info Capacity in <br /> Gallons Total #Of <br /> dGallons Units Manufacturer <br /> New Tanks Existing Tacks <br /> — <br /> U iin H A wa C7 P. <br /> Septic or Holding Tank 2000 a 2000 1 WIESER CONCRETE ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber W1 ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigm ev a responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PIttatureMPRS Number Business Phone Number <br /> CORYJACKSON 82339 715.566-2786 <br /> Plumber's Name(Print) PI <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 9306 BLACK BROOK RD. WEBSTER,WI 54893 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fete Date Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial I $ <br /> M Conditions of Approval/Reasons for Disapproval p / <br /> P104 Raw SJtouJs Tfltik )j plareAewi �r e v O oNl A �LDa /O air.. <br /> Attach to complete plans for the system and submit to the Comfy only on paper not less than 8 la i l l inches in size <br /> SBD-6398(R03/14) <br />