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o�LHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY&r <br /> STATE NITARY RMIT#' gCOC) <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than o o Oo illi <br /> 8'/z x 11 inches in size. ❑ Checrevlar previous application <br /> —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPfERTY LOCATION <br /> John MuAphy N W '/a ''/s,S 6 T 40 , N, R 16 E(or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 1999 Nokomis Avenue 8 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> St. Paul, MN 55119 612 735-8829 CSM Vol. 12, pg. 90 <br /> I1. TYPE OF BUILDING: Check one) CITY NEAREST ROAD <br /> ( State Owned VILLAGE Uahkand Pandun Road <br /> ❑ Public ❑1 or 2 Fam. Dwelling—#of bedrooms � MER( ) <br /> 111. BUILDING USE: (If building type is public,check all that apply) 20-4306-01 230 <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. 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 Permit was previously issued. Permit# 151350 Date Issued 12-6 91 <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 DAY 12.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. 'ERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.h.) (Gals/day/sq.h.) (Min./inch) ELEVATION <br /> 300 410 420 .71 3 96.2 Feet 1 98.5 Feet <br /> VII. TANK CAPACITY site <br /> INFORMATION in as on Total #of Prefab. Fiber- Exper. <br /> New istin Gallons Tanks Manufacturer's Name ConcreteCon- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 750 750 1 1 TMC X <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:(N mps) MP/MPRSW No.: Business Phone Number: <br /> Wade RuAehotm 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.U. Box 514 S ' en, W7 54872 <br /> 11L jCOUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee(Includes Groundwater Date Issued Issuing&givt Si re(N t ps) <br /> L <br /> Approved ❑ Surcharge Fee) <br /> Owner Given Initial _Q1LV <br /> Adverse Determination 00 <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/89) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />