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SANITARY PERMIT APPLICATION COUNTY <br /> 17-QILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> .e.,...�...,�,�� STATEANITARY RMIT <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ IZ7J <br /> 8%x 11 inches in size. 1rewslo opreviousapplication <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 PROPERTY LOCATION <br /> BA an We<dendanb '/a Ya,S 24 T 41 , N, R 17 E (or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> Rt. #1 Box 205 3 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Mona, MN 55051 612 679-5218 Lot 3, CSM Vof. 13, P . 154 /n 0V=E. LLo- <br /> 11. TYPE OF BUILDING: (Check one) El CITY NEAREST ROAD <br /> ❑ State Owned VILLAGE SW2dd Hwy. 70W <br /> ❑ Public ®1 or 2 Fam.Dwelling—#of bedrooms L R( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) <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 ® 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 PER7DAY2.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.ft.) (Min./inch) ELEVATION <br /> 3 480 480 .63 4 95.6 Feet 98 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Expp. <br /> INFORMATION New istin G101 ions Tanks Manufacturer's Name CPC Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank 750 750 1 1 TMC <br /> Litt 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 plans. <br /> Plumber's Name(Print): Plumber's Signature: 0 Stamps) MP/MPRSW No.: Business Phone Number: <br /> (Dade Rub,AoRm C� 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.O. Box 514 Aen,0/I 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fae(Inclutlea Groundwater as ssue Issuin tSignatura IN St ps) <br /> Surcharge Fee) _ <br /> Approved ❑ Owner Given Initial �/' <br /> Adverse D rmination A• 11 <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&Buildings Division,Owner,Plumber <br />