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SANITARY PERMIT APPLICATION <br /> a In accord with ILHR 83.05,Wis.Adm.Code cou Tv :-- <br /> �,C/I�e <br /> STA ESA TARY RM <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ 1 I� y-)3 <br /> 8%x 11 Inches in size. heck if revision to previous application <br /> —See reverse side for Instructions for bompleti ng this appl kation. STA E PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Steve Anderson for Bill c '/4 ''/a,S 14 T 40 , N, 15 �(or)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOC # <br /> 16315 Co. Rd. 45 14 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Carver,MN 55315 612 48-3082 CSM Vol. 11, P . 192 <br /> TY <br /> 13 CITY I1. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE : NEAR ST ROAD <br /> OF Jackson Mitchell Road <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms 3 PAR L AX NUMBER( ) <br /> III. BUILDINGUSE: (If building type is public,check all that apply) C./g— <br /> � 1Z' <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Res aurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Se ice 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: (Check 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 7 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.tt.) (Min./inch) ELEVATION <br /> 450 643 648 .69 NA 1.7 Feet 94.2 Feet <br /> VII. TANK CAPACITY Site <br /> in alloIT Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank 1,00 11,000 1 1 Skew 191 <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached p ans. <br /> Plumber's Name(Print): Plumber's/Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Rufsholm 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.O. Box 514 Siren WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee(IncludGroundwater ate IssuedIssuin g nt Si net ( St <br /> � s) <br /> pproved El Given Initial es wo rge Fee) <br /> Adverse Determination PU I <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.oB/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Ow at,Plumber <br />