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SANITARY PERMIT APPLICATION <br /> DILHR In accord with ILHR 83.05,Wis.Adm.Code COUNTY r-> <br /> ATE SANIT YPERMIT# <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than 07�Ar() <br /> 8%x 11 Inches In size. Check if revision to previous application <br /> –See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Dave and Linda Swanson '/s '/4,S 20 T 40, P I, R 14 R(or)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLC CK# <br /> 506 17th Ave. N. Outlot 1 CI <br /> CITY,STATE I ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSMNUMBER <br /> So. St. Paul, MN 1 55075 612 949-6012 J4 � 1 <br /> It. TYPE OF BUILDING: (Check one CITY NE REST ROAD <br /> State Owned VILLAGE Scott County Road A <br /> ❑ Public ®1 or 2 Fam.Dwellings of bedrooms— PARCEL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) it f la,O -U <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Of tdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Re staurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ SE rvice Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ 01 ier: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. ® New 2. ❑ Replacement 3. ❑Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit# — Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 Q Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAI 2.ABSORP,AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE . SYSTEM ELEV. 7. FINAL GRADE <br /> 300 REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 630 630 .48 13 95.4 Feet 98 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank 0 -- 800 1 1 Skaw <br /> Lift Pump Tank/Siphon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's <br /> Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Rufsholm 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.O. Boa 514 Siren, WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Pe mit Fee(Includes Groundwater Datessue lwuin ant Sig ur (No tamps) <br /> Approved ❑ Owner Given Initialharge Fee) _ <br /> Adverse Determination l�O <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/89) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,0 ner,Plumber <br />