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o�LH 2 SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNT,* <br /> r <br /> �ry�• � STATES ITARY�RMIT#�On�pT <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than I'q�/\ / cy.� <br /> 8%x 11 inches in size. El Check If revisidcAo 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. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> John and Teneha Kendnich 'A '/4, S 24 T N, R 17 R(or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 1610 St. Cath Ave. 9 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> St. Paul, MN 55105 612 699-3903 CSM Vol. 13, Pg. 158 <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> n ❑State Owned VILLAGE: Swizz St. Hwy. 77 <br /> ❑ Public UU 1 or 2 Fam. Dwelling-#of bedrooms <br /> III. BUILDING USE: (If building type is public,check all that apply) <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. ® 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 12.ABSORP.AREA 3,ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 150 240 432 .35 4 96.2 Feet 98'7 Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #ot ManuTacturer'sName Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New istin Gallons Tanks oncret glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Hoidin Tank <br /> Lift Pum TanWSi hon Chamber '-- 60� <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: o Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Ru6zho m //L�� , 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.U. Box 5141 S Aen, WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(lncludee llmundweter a eau Issuln ent Sign a(No Stempa) <br /> �eSurcharge Fee) �J <br /> Approved ❑ Owner Given Initial 135,co � <br /> v rmin ti n <br /> X. 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 />