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D�LHR SANITARY PERMIT APPLICATION COUNTY <br /> � In accord with ILHR 83.05,Wis.Adm.Code um <br /> STATE SANITARY PERMIT# <br /> –Attach complete plans(t the county copy only)for the system,on paper not less than ❑ j 7SSV <br /> 8'%x 11 inches in size. C ack if revist6n to previous application <br /> —See reverse side for instructions for completing this application. STATELAN I.D.NUMBER <br /> I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. LI—SIO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Bob and Judy Phiti e Y4 ''/4, S 21 T 37 , N, R 1g (o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 1810 Uakeaeet Avenue 7 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Rozevitte MN 55113 612 631-9431 CSM Vot. 1 Pa. 159 i t c�— <br /> II. TYPE OF BUILDING: ( heck one) El <br /> CITY NEAREST ROAD <br /> ❑State Owned vILUGE 7h B view Dhive <br /> ❑ Public X❑1 or Fam. Dwelling hof bedrooms ZPARCEL <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo T <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. X❑ 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 Perm it was previously issued. Permit# — Date Issued <br /> V. TYPE OF SYSTEM: (C eck only one) <br /> Non-Pressurized Distrit ution 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 /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 NA NA NA NA I NA Feet NA 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 Holding Tank 2,001 - 12,000 1 1 Sk <br /> Litt Pump Tank/Siphon Chambe <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): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> (Dade Rubeho2xn lz,/�.— 3361 115 349-7286 <br /> Plumber's Address(Street,City state,Zip Code): <br /> 24702 Lind Road P.U. Box 514 StAen, (UI 54872 <br /> I . COUNTY/DEPARTMENT USE ONLY <br /> Lj Disapproved Sanitary Permit Fee(Includes Groundwater a e ssu Isa n Agent Signature(No Stamps) <br /> y I e 3uroherae Fee) L/ <br /> Approved ❑ Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APP OVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.1 /88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />