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7DILHR SANITARY PERMIT APPLICATION <br /> COUNTY <br /> v In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE/���AAAr `t <br /> NITAR ERMIT#JG00g3 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than �/to � O <br /> 8t%x 11 inches In size. ❑ Check if revisidn revs ' 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. S —aV <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Ken 9 Don is Gnant %4 N5_%,S 35 T41 N, R I E (o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 3457 Buchanan St. NE 2 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Minneapotiz, MN 55418 715 656-3137CSM Vo.e. 9 P . 1 3 <br /> Il. TYPE OF BUILDING: (Check one) El State Owned VILLAGE NEAREST ROAD <br /> ISI • S(u2aa Mtnehva Dam Road <br /> ❑ Public [il 1 or 2 Fam. Dwelling-#of bedrooms 3 <br /> Ill. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo <br /> 2 ElAssembly 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. X❑ 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 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) I (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 450 ------ --------- --------- ------- --- Feet ---- Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank 2.00 1 2,0001 2 <br /> LiftPum Tank/Si hon 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 S s) MP/MPRSW No.: Business Phone Number: <br /> Wade Ru4zho m 1 4/( 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.U. Box 514 S•ihen W1 54872 <br /> LINTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(inoiudw Groundwater Date IssuedIssuing Agent ' natur (No Sta s) <br /> roved 'j 1,36, _ Surcharge Fee) <br /> pp Owner Given initial lFJ{i`/l <br /> AdverseDetermination <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 />