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SANITARY PERMIT APPLICATION <br /> 70ILHR In accord with ILHR 83.05,Wis.Adm. Code COUNTY <br /> STATE SANITAllTf//7t,3 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8'%x 11 inches in size. ❑ Check if rev on 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 9/503-3L-A-'WD <br /> CATION <br /> Tom Patmen '/4,S 3 T 37, N, R 18 E (or) <br /> PROPERTY OWNER'S MAILING ADDRESS BLOCK# <br /> 4219 Fhemont Avenue <br /> CITY,STATE ZIP CODE PHONE NUMBER NAME OR CSM NUMBER <br /> Minneapotib, MN 55412 1 4 SE 1 4II. TYPE OF BUILDING: Check one) NEAREST ROAD <br /> ( State Owned Thede lake West Spiait Lake Road <br /> ❑ Public X❑1or2Fam. Dwelling-#ofbedrooms� NUM E �n/�T BUILDINGUSE: (If building type is public,check all that apply) <br /> 3Y— <br /> Ill. /503-3�-'/v v <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. X❑ 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 X❑ 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.ASSORP.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 /> 300 480 480 .63 1 92.97 Feet 96 Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name c ncret Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Se ticTankor HoldinclTank 800 8001 Skald <br /> Lift Pum 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: oStamps) MP/MPRSWNo.: Business Phone Number: <br /> Wade Rubhbho2m 3361 If715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.U. Box 514 Schen, W1 54872 <br /> IX. OUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee(includes Groundwater ae ssue IssuingSlgnat No <br /> Approved ❑ Owner Given Initial y}.}- �v-�surcharge Fee) <br /> Adverse Determination 4+" `�'CD <br /> CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />