Laserfiche WebLink
SANITARY PERMIT APPLICATION <br /> Ive�r�fr�i In accord with ILHR 83.05,Wis.Adm. Code COL NTY �Q <br /> E SANITARY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �/fl0(,d�d\J \J rJ�-\iJDp <br /> 8%x 11 Inches In size. Check if revision to previous application <br /> -See reverse side for instructions for completing this application. STA rE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Lauri Jorgenson %4 '/4,S 6 T 41 , N, R 16 (or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOC # <br /> 3678 Majoe upirilip N_ <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Robbinsdale, MN 55422 12 540-1272 Vol 12 P 112 <br /> It. TYPE OF BUILDING: (Check one) ❑State Owned 0 VILLAGE:Ty <br /> NEAREST ROAD <br /> ❑ Public ®1 or2Fam. Dwell Iing-(#ofbed rooms? PAR EL TAX NUM ER(S) Min rval Circle <br /> III. BUILDING USE: (It building type is public,check all that apply) Q , - .. _ ' <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Res aurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Ser ice Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: 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 ® Seepage Bed 21 ❑ Mound 30 ❑ Speciry 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 DAY 2.ABSORP.AREA 13.ABSORP.AFtEA 4. LOADING RATE '_ 'E" <br /> . PERC.RATE 6. YSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 429 432 .69 NA 92.5 Feet 95 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total ##of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- feel glass Plastic App <br /> Tanks Tanks structed <br /> Se tic Tank or Holdina Tank 800 800 Skew <br /> Lift Pum Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:(No tamps) 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. Box 514 Siren, WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary P rmit F���aae(includes Groundwater a e ssue Issuing Ag t Signatu a(No Sta Pa) <br /> Approved Downer Given Initial [�u urge Fee) 1 <br /> Adverse Determination o 1 <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-6398(R.0893) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Own r,Plumber <br />