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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couNTr l Jt1� <br /> STATE SAN ITAR'YI/MA MIT 40Z <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than x 11 inches in size. Ch❑ f <br /> 8'% if revisi I 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 PROPERTY LOCATION <br /> Dave KeKby % %,S 4 T , N, R 15 E(or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 5509 MiAAoh Laken DAIve <br /> CITY,STATE ZZII 5CODE PHONE NUMBER SUBpMSIONME OR CSM NUMBER <br /> Aql Edina, MN 77 e-M cc�1SS1� -:1 , "t.. LOT- <br /> 0 <br /> 11. TYPE OF BUILDING: (Check one) ❑State Owned VILLLAGE:TY NEAREST ROAD <br /> LaEottette Beh#icam Road <br /> ❑ Public ®1 or 2 Fam. Dwelling- of bedrooms 2 PARCEL TAX NUMBER(S) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) 14- �aaq- D7 6cO <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 ❑ 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 12.ABSORP.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 4 96.7 Feet 99.6 Feet <br /> cAPAcIrY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New isfin Gallons Tanks Manufacturer's Name oncre Con- Steel glass Plastic App <br /> Tanks I Tanks structed <br /> Se tic TankorHoldin Tank 800 800 1 Skaw <br /> Lift Pump Tank/Siphon Chamber Ei <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 /> Glade Ru6zhokm 1 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> P.O. Box 514 SiAen, G/I 54872 <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(lnc�u�nater a esu Iss gent S' ture(No Stamps) <br /> Approved ❑ Owner Given Initial 1151- C0 _�� <br /> Adverse Determineion __77 LLJ U--"I <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />