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D1LHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code Burnett <br /> STATE SANITARYERMIT#aoq� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ ��� <br /> 8'%x11inches insize. eckirrevi'i to previous application <br /> —See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. 4011110 <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Wesley Nicholson '/4 '/4, S 4 T40 , N, R 14 ll �d W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 5426 Scott Ave N '$ (jpv!t,LoT 4 1 na <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Crystal MN 5542 612 535-6861 na <br /> I. TYPE OF BUILDING: (Check one) CITY <br /> INEAREST ROAD <br /> 14 U TOWN OF: <br /> ❑State Owned VILLAGE: Scott County H <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms -i I PARCEL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) 028 - 4104 - 02 - 500 <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 ❑ 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: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 U 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 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 9110 450 REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 720 720 Feet inn in Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New iatin Gallons Tanks Manufacturer's Name oncre Prefab Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank 1000 -- 1000 1 Saw mf om <br /> Lift Pum Tank/Siphon Chamber 600 - 600 1 <br /> Vlll. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> ml <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels 1. t 01(7� MP 330 715 349-5533 <br /> Plumber's Address Street,Clty State,Zip Code): <br /> PO Box "T1691 Siren WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Lj Disapproved Sanitary Permit Fee(Includes Groundwater Date IssuedIssuing A e Igoe[ a(No ps) <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial _4 f 3S` CO ?Q-L'-q <br /> Adv Determin I n � <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />