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• <br /> ,...consln APPLICATION FOR SANITARY PERMIT N' <br /> D I L H R (PLB 67) UI).-ziCOUNTY <br /> UNIFORM SANIT Y PERMIT# <br /> � OEPRRTTEnT OF <br /> monsumuma InDUSTRV,LRBOR&HUTRf RELRTIOfS �� 759 //4/354) <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> Dan Marsh 4350 Chicago Ave. S. Minneapolis MN 55407 <br /> PROPERTY LOCATION /QtJM1 <br /> SE 1/4 NW1/4, S 8 , T39, N, R 17i/fdr4 W TOWN OF: Lincoln <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> na na na Beal Road <br /> TYPE OF BUILDING OR USE SERVED <br /> iX] 1 or 2 Family Number of Bedrooms: 2 ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> • New System ❑ Tank Replacement ❑ Repair <br /> ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> • Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank <br /> El System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy <br /> ❑ Existing, For Which A Previous Permit Is On File, Permit # issued <br /> ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. <br /> Total #of Prefab. Site Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity 750 750 X <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: TMC Inc. <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Total #of Prefab. Site Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity OW It <br /> Lift Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> 3 Lie0 qLO ] Private LJ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na e of Plumber (P int): Signature , / MP/401‘44434,4/15.: Phone Number: <br /> 1 IanR1d L n1eIs ,� /, 33, (715)03 -233.3 <br /> Plumber's Address: Name of Designer: <br /> Ibiti" 14 SE M1 WI 6-01)-- 5RP4 e. <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> (/i 6j.."2:4-ZY A roved E] Owner Given Initial <br /> PP Adverse Determination <br /> ason for Disapproval: 1.-.) <br /> Alternate course(s)of Action Available: <br /> DILHR-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />