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MREM�_Rn SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis. Adm. Code COUNTY <br /> r G <br /> STATE��ANITA ERMIT#,� * <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ � I� <br /> 8%x 11 inches in size. c k it rev' n 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. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Betty IaBarre '/4 '/4, S 34 T 41, N, R 16 E (or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 130 Hwy 96-Dellwood 2 <br /> CITY,STATE ZIP CODEPHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> White Bear Lake,MN 55110 CSM Vo1.7, Pg. 111-112 Gov. Lot3 <br /> IL TYPE OF BUILDING: Check one) CITY NEAREST ROAD <br /> ( State Owned VILLAGE SWISS <br /> Lon Lake Road <br /> ❑ Public ©1 or 2 Fam.Dwelling bedrooms LTAXNUM //-�� <br /> Ill. BUILDING USE: (If building type is public,check all that apply) — 5334- ba- ,56o <br /> 1 ❑ ApUCondo <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 ❑ SpecityType 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 PE77 2.ABSORP.AREA 13,ABSORP.AREA 14. LOADING RATE 15. PERC,RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 480 480 .63 2 1 94.6 Feet 97 Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #ofame Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's NConcreteCon- Steel glass Plastic App <br /> Tanks 1 Tanks structed <br /> Septic Tank or Holdina Tank -- 75O 1 l Wieser Concrete <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'sSignal re:(No mps) MP/MPRSW No.: Business Phone Number: <br /> ' <br /> Wade Rufshohn [,) / 3361 ) 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.O. Box 514 Siren WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater I Date Issped ssuing Ap Signal e((No Sia ) <br /> CL /4' <br /> Approved ❑ Owner Given Initial Surcharge Fee) <br /> A vane Determination /05• M <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 />