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` r4n County <br /> Industry Services Division Bumett 1400 E Washington Ave <br /> P.O. Box 7162 Sanitary Permit Number(to be filled inb Co. <br /> Madison,WI 53707-7162 �PlJ-Iq-�3 �'/! D <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 forms 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. 2224 Point road <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> ROCHELLE B&MICHAEL J GONZO 07-024-2-39-14-09-5 05-001-016000 <br /> Property Owner's Mailing Address Property Location <br /> 7224 UPPER 136TH ST W <br /> Govt.Lot 1 <br /> City,State Zip Code Phone Number '/4, '/4, Section 9 <br /> APPLE VALLEY,MN 55124 (circle one) <br /> T39N14; RwEorW <br /> I1.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> ❑Public/Commercial—Describe Use Block# <br /> ❑ City of <br /> ❑State Owned—Describe Use <br /> CSM Number ❑ Village of <br /> ® Town of Rusk <br /> III. pe 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.Dis ersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 Rate(gpdsf) 642 652 91 <br /> .7 <br /> VI.Tank Info Capacity in <br /> a+ b U Gallons Total #of Manufacturer U <br /> New Tanks Existing Tanks Gallons Units v o $ at <br /> a U in rq Ti. <br /> Septic or Holding Tank x I Wieser ® ❑ ❑ ❑ <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) i>_ <br /> r' ' ature MP/MPRS Number Business Phone Number <br /> Luke Schmitz 1 984121 715-520-2434 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 160 Shell Lake WI 54871 <br /> VIIL Coun /De artment Use Only <br /> [Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Si ure <br /> ❑Owner Given Reason for Denial $ 3 7- / .S ZS <br /> IX.Conditions of Approval/Reasons for Disa R <br /> PPROVED M U V H= <br /> MAY 2 0 I'll <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I T- e COUNTY <br /> ZONING <br /> SBD-6398(R03/14) <br />