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SANITARY PERMIT APPLICATION COUNTY ^ 1 <br /> DILHR In accord with ILHR 83.05,Wis.Adm.Code Ll N <br /> �• �_ STATES ITARY RMIT# <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ('bb-�.� 10U <br /> 8'%x 11 Inches In size. ❑ Check if revisio o previous application <br /> -See reverse side for Instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Brian WeidendoAA '/4 '/4, S 24 T 41 , N, R 17 E(or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> Rt. #1 Box 205 1 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Mona, MN 55051 612 679-5218 CSM Vot. 13, Pg. 154 )�n DV'-t. LoT <br /> 11. TYPE OF BUILDING: (Check One) CITY NEAREST ROAD <br /> ❑State Owned VILLAGE: $WiAh Hwy. 77 W <br /> ❑ Public ®1 or 2 Fam. Dwelling–#of bedrooms Z A NUMB <br /> 111. BUILDING USE: (If building type is public,check all that apply) 3a - 5a - o <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 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service 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 M 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 DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERI.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 480 480 .63 3 96.5 Feet 98.9 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 150 --- F50 1 I T <br /> PIC Li I LL <br /> Lift Pump Tank/Siphon 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: Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Ru{Ieho& � � 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 /> X COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater) a e slue Issuing A e ignat (No ps) <br /> /`�7�surcharge Fee <br /> Approved ❑ Owner Given Initial I •W - <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />