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SANITARY PERMIT APPLICATION r <br /> 01LHR In accord with ILHR 83.05,Wis.Adm.Code DUN <br /> • � STATESANITAR ERMIT# � <br /> -Attach'complete plans(t the county copy only)for the system,on paper not less than ❑ �'/ II <br /> 8'%x 11 inches in size. C Ir revl,�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. 1PROPERTY OWNER PROPERTY LOCATION <br /> Jim Warnecke '/4 ''/4,S 20 T 37 , N, R 18 (or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 7830 132nd StAe Z 7 <br /> CITY,STATE21P CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Hugo, MN 55038 612 426-1249 CSM Vot. 14, Pg. 92 1"/,) 't, Lor <br /> II. TYPE OF BUILDING: (Check One) CITY113 <br /> NEAREST ROAD <br /> ❑State Owned VILLAGE TAade Lake Cedars Point Road <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms 2 A u —7 <br /> Ill. BUILDING USE: (If building type is public,check all that apply) !Q <br /> 1 ❑ Apf/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: ( heck only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 ❑ 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 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADINGRATE 15. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> R OUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 NA NA NA NA NA Feet NA Feet <br /> VII. TANK Mingallons <br /> Site <br /> Total #of Prefab. Fiber- Exper. <br /> INFORMATION Gallons Tanks Manufacturer's Name oncretCon- Steel glass Plastic App strutted <br /> Se tic Tank or Holdin Tank kaw <br /> Lift Pum Tank/Si hon Cham <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. Ruohotm - c 3361 715 349-7286 <br /> Plumber's Address(Street,CiState,Zip Code): <br /> 24702 Lind Rua , P.U. Box 514 Sinen, W1 54872 <br /> IX.,COUNTYIDEPARTMI NT USE ONLY <br /> ❑ Disappro ed Sanitary Permit Fee(Includes Groundwater DateIssuedU I;Sul ant Sign (No Stamps) <br /> Surcharge Fee) Cl% <br /> Approved ❑ Ownere1 termiin _$ )5 . �—, <br /> Adverse min tion U (_ ~_ <br /> X. CONDITIONS OF APP OVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R. 1/98) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />