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SANITARY PERMIT APPLICATION <br /> La �� In accord with ILHR 83.05,Wis.Adm.Code Co TY <br /> STA FEAANITArRY PET <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8'%x 11 inches in size. <br /> Check if re ision to previous application <br /> —See reverse side for Instructions for completing this application. STA E PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Mark Harmon '/4 '/4,S 36 T 40 , N, R 15 EX(or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 8216 Oregon Circle 1 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Bloomington, MN 55438 CSM Vol. 14, Pg. 123 <br /> 11. TYPE OF BUILDING: (Check one CITY NEAR ST ROAD <br /> State Owned 0 VILLAGE <br /> 1:1Public Jackson Thompson Ba Road <br /> ®1 or 2 Fam. Dwelling-#of bedrooms R L IAXNUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) old - 3 <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Out oor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Res aurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Ser 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) ElA Sanitary Permit was previously issued. Permit# Date Issued—4- la_&4 <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 NSeepage Bed 21 ElMound 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 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERI.RATE 6. YSTEM ELEV. 7. FINAL GRADE <br /> 300 REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq. <br /> ft.) <br /> (Min./inch) ELEVATION <br /> 375 390 .78 NA 8 Feet 100.5 Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Manufacturer's Name Prefab. CSteel Fiber- plastic Exper. <br /> INFORMATION New xistin Gallons Tanks Concrete on- glass App. <br /> Tanks Tanks structed <br /> Se tic Tank or Holding Tank 800 -- 800 1 1 Skaw <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 plans. <br /> Plumber's Name(Print): Plu'm'ber/'s Signature: Stamps MP/MPRSW No.: Business Phone Number <br /> lm : <br /> Wade Rufshol/f/czt�� 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 LindRoad P.O. Box 514 Siren WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary PerQ.It Fee(Includw Groundwaterae issued Issuin A it gnat rej(Nf Stamps) <br /> Approved ❑ Owner Given Initial 11 ��rge Fee) L LK <br /> �� <br /> Adverse Determination --ILP <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SB66398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Own r,Plumber <br />