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nn _y4 <br /> Safety an uil gs Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> ■ P O Box 7302 <br /> `Asconsin In accord with ILHR 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> Department of commerce <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County01.D.Number <br /> t a4D/rj <br /> than 812 x 11 inches in size. <br /> State Saumber <br /> • See reverse side for instructions for completing this application Personal information you provide may be used for secondary purposes ❑eneckiou application[Privacy Law,s. 15.04(1)(m)). State Pl <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION TransTD#323577/site# 194430 <br /> Property Owner Name Property Location <br /> Lowell Wheeler GL 2 1/4 1/4,S 2 T 37 N R 18 /� )W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 417 5th Ave SE <br /> na na <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Minnea lis MN 55414 ( > na <br /> ity Nearest Road <br /> 111 TYPE F B ILDING: (check one) ❑ State Owned ❑ village <br /> Public 1 or 2 FamilyDwellingNo.of bedrooms _3__ Town OF Trade Lal.e Spirit Lake Rd <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 034 - 1502 0 02 100 <br /> 1 ❑ Apartment/Condo <br /> 10 Outdoor Recreational Facility <br /> 2 E] Assembly Hall 6 ❑ Medical Facility/Nursing Home ❑ <br /> 3 E] Campground 7 ❑ Merchandise:Sales/Repairs <br /> 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 box on line A. Check box on line B,if applicable) <br /> New 2_ Replacement 3. ❑ Replacement of 4, ❑ Reconnection of 5. ❑ Repair of an <br /> A) 1. ❑ l Existin System Existin System <br /> System System Tank ON _____ 9 Y__________________�-_ <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number 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❑Specify Type 41 ❑Holding Tank <br /> 22 In-Ground Pressure 42[1 Pit Privy <br /> 12 El Seepage Trench ❑ 43 E]Vault Privy <br /> 13 E]Seepage Pit <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. Perc. Rate 6. System Elev. 7. Final Grade <br /> 450 Requi 37�sq.ft.) Proposed(sq.ft.) (Gals/�ay/sq.ft.) (Mi nainch) 97.60 El_ 68ti60 <br /> 375 Feet Feet <br /> VII. TANK Capauty Total #of site Fiber- 4PIasticxpec <br /> ingallons Manufacturer's Name Concretecon- Steel glass AppINFORMATION New Existin Gallons Tanks structed <br /> Tanks Tanks ® El <br /> Septic Tank or Holding Tank 1000 -- 1000 1 Wieser Concrete ® ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 600 -- 600 l Wieser comb <br /> VIII. 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) be( gna e:(No amps) MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels MP330/221593 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> PO box 316 Siren WI 54872 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee lincludesGroundwater ate ssue Issuing ent Signature(No Stamps) <br /> ❑ pp Surcharge Fee) <br /> A I pproved ❑Owner Given Initial �rn �j` '� <br /> Adverse Determination O'�-lJ• <br /> NDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: original to County,One copy To: safety 8 Buildings Division,Owner,Plumber <br /> SBD-6398 IRA 1/97) <br />