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SANITARY PERMIT APPLICATION <br /> la�.ILHR In accord with ILHR 83.05,Wis.Adm.Code CO11NTMb, <br /> r <br /> STATE NRARY ERMIT# <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than }–71`fI ao �iq <br /> 8%x 11 inches in size. ❑ ch kitrevislo to 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. 5q3-aOsgs <br /> PROPERTYOWNER PROPERTY LOCATION <br /> MaAy Wyatt 1/4 %, S 11 T37 , N, R 18 E(or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT// BLOCK// <br /> 309 Jenka <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> St. Pain, MN 55101 612 774-6469 pct. G.L. i <br /> 11. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> state Owned VILLAGE. Tnade Lake Spdndt Lake Road <br /> ❑ Public ®1 or 2 Fam.Dwelling-#of bedrooms 2 <br /> III. BUILDING USE: (If building type is public,check all that apply) /I 1511—_ ci _a� <br /> 1 ElApt/Condo lJ <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestaurantIBar/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 PER DAY 2.ABSORP,AREA 3.ABSORP.AREA 14. LOADING RATE 5. PERS.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.11 (Mindinch) ELEVATION <br /> 300 NA NA I NA I NA I NA Feet NA Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name ncret Cort- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdina Tank <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 Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Ru lshotm 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.O. Box 514 S ween, W1 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued 1 gent Sig re No Stamps) <br /> Approved ❑ Owner Given Initial _ Surcharge Fee) 9 a <br /> A v t rmin tin I a�' LTU /• J <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />