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SANITARY PERMIT APPLICATION 5STATE <br /> 7_01LHR In accord with ILHR 83.05,Wis.Adm.Code h �,(�r�I <br /> Q� NITA RMI #001) <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than � <br /> 812x11inchesinsize. cklrrew on to previous application <br /> -See reverse side for instructions for completing this application. LAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Michael 8 Mmitynn Vast t/4 '/4,S 7 T40 , N, R 16 E(or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 1410 Quant Ave. 19 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> MaAine on St. CAoixA 55047 612 433-2719 Riven Oaks Subdivision <br /> PITY NEAREST ROAD <br /> it. TYPE OF BUILDING: (Check one) El State Owned 0 VILLAGE;Oaktnad west yettow Riven Road <br /> ❑ Public 01 or 2 Fam.Dwelling-#of bedrooms 3 Ax INUMB F K( ) <br /> 111. BUILDING USE: (If building type is public,check all that apply) .( — -L1�1� <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 0011 ice/Factory 13 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. L,� 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 El Specify Type 41 El 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. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.tt.) (Min./inch) ELEVATION <br /> 450 720 720 .63 4 96 Feet 98.4 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total Of Prefab. Fiber- p . <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete A <br /> Con- Steel glass Plastic App. <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or H Idina Tank 11 ,0011i --- 1 ,000 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): Plumber's Signature:(No tamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Ru shoe» 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip e): <br /> 24702 Lind Road P.O. Box 514 SiAen wI 54872 <br /> IX COUNTYIDEPARTMENT USE ONLY <br /> Disapproved 1 Sanitary Permit Fee(Includes Groundwater a e asu Issuing Sign urs( o tamps) <br /> Approved ❑ surcharge Fee) <br /> Owner Given Initial / c/ /Zr��1 <br /> A v e rmi ionse�h�°Vv <br /> X C NDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />