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lILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTY BU r <br /> STATE Zk)i <br /> ITAR MIT#� I I q q <br /> —Attach complete plans(t the county copy only)for the system,on paper not less than 1 oC 1� 1 <br /> 8%x 11 inches in size. ❑ ch lvieion previous application <br /> —See reverse side for 1 nstr uctions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMAT ON—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Monte Bute '/4 '/4,S 18 T 40 N, R 16 f (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 2214 Univenaity A e. N.E. 8 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Mineapolis, MN 55418 Second Add. to Pandunls RiveA Pines <br /> I1. TYPE OF BUILDING: (C heck one) ❑State Owned 1:1 CITY O VILLAGE NEAREST ROAD <br /> Uahtand E. Ve tow Riveh Road <br /> ❑ Public Z 1 or Fam.Dwelling-#of bedrooms 2 UMBER(5) <br /> 111. BUILDING USE: (If buil ling type is public,check all that apply) <br /> 1 ❑ Apt/Condo l/ IJLJ <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: (Ch k 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 Perm t was previously issued. Permit# IJSJ� Date Issued - � <br /> V. TYPE OF SYSTEM: (CI eck only one) <br /> Non-Pressurized Distrib ition 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 SYSTER I INFORMATION: <br /> 1.GALLONS PER DAY 2. BSORP.AREA 13.ABSORP.AREA 14. LCADINGRATE 5. PERC.RATE 16. SYSTEMELEV. 7. FINAL GRADE <br /> RE UIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 410 414 .72 3 96.2 Feet 98.7 Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #Of Prefab. Fiber- Exper. <br /> INFORMATION New !sting Gallons Tanks Manufacturer's Name ConcreteCon- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank <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's Signature: Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Rubehotm /� fir✓ 3361 715 349-7286 <br /> Plumber's Address(Street,City, 3tate,Zip Code): <br /> 24702 Lind Road P.U. Box 514 Sihen, U/I 54872 <br /> IX, COUNTY/DEPARTME T USE ONLY <br /> Disapprove Sanitary Permit Fee(Includes Groundwater aessue Is ng gent Signatur (No Stamps) <br /> Approved cµ,y /�'` surcharge Fae) <br /> pp Owner Giv nInitial ,— 150o � <br /> A ve eD <br /> main ti n <br /> X. CONDITIONS OF 4R VAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly iTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />