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SANITARY PERMIT APPLICATION C UNITY Burnett <br /> 7 DILHR In accord with ILHR 83.05,Wis. Adm. Code <br /> TIATESANITARY PERMIT# <br /> MEN � <br /> D5 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than SI ATE PLAN I.D.-NUMBER <br /> 8'h x 11 inches in size. S88-20096 <br /> -See reverse side for instructions for completing this application. PE TITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑x NO <br /> PROPERTYOWNER PROPERTY LOCATION <br /> Joseph Gunderson N NjSE +% SW +/4, S 24 T 40 N, R 7 xXjWW <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME <br /> 10071 75th St. N. na na na <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST OAD,LAKE OR LANDMARK <br /> Stillwater, MN 55082 612 439-8743 ❑ VILLAGE: Union N. Y llow Lk. Rd. <br /> f-1 TOWN OP <br /> It. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 2 OR ❑ Public(Specify): <br /> 111. PURPOSE OF APPLICATION: (Check only one in#1. Check#2.3 or 4,if applicable) <br /> 1. a. ❑ New b. ® Replacement c. ❑ Replacement Of d.❑ Reconnection of e ❑ Repair of an <br /> System System Septic Tank Only an Existing System Existing System <br /> 2. ❑ A Sanitary Permit was previously issued. Permit# Date Issued <br /> 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. <br /> 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreemi nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. ❑Conventional b. ® Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding C.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ® IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. ©Seepage Bed b. ❑Seepage Trench c. ❑ seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> 3 252 252 97.15 Feet F rivate El joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Ste I glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 750 750 1 TMC Inc. x ❑ <br /> Lift Pump Tank/Si hon Chamber 1750 - 750 1 TMC Inc. ❑ x ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached planE. <br /> Plumber's Name(Print): Plum is Signature:(No Stamps) MP/MPRSW No.: B siness Phone Number: <br /> Donald Daniels MP 330 15 349-5533 <br /> Plumber's Address(Street,City,State,Zip Cod Name of Designer: <br /> Box W Siren, WI 54872 r <br /> ame <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name EPhon�e <br /> Joan E. Daniels 1 <br /> CST's ADDRESS(Street,City,State,Zip Code) er:Box W Siren, WI 54872 349-5533 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agents natureure(No <br /> Approved Surcharge Fee �Q/(J <br /> pp ❑ Owner Given Initial On rn.T, 5—I�, <br /> Adverse Determination <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD 6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumbs <br />