Laserfiche WebLink
0ILHR SANITARY PERMIT APPLICATION COUNTY <br /> BU.RNETT <br /> In accord with ILHR 83.05,Wis. Adm. Code <br /> STATESANITARY ERMIT# <br /> a <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NU ER <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> DARREL SODREN SE '/4 NW '/4, S 12 T 39, N, R 14 )tA of W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> 8100 82nd AVE NO BROOKLYN PARK MN NA NA NA <br /> CITY,STATE I ZIP CODE PHONE NUMBER U CITY NEAREST ROAD,LAKE OR LANDMARK <br /> K e 4.4 VILLAGE: RUSK NO LIPSIE LK RD <br /> Il. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 2 OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. ❑ New b. ❑% Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an <br /> System System Septic Tank Only an Existing System Existing System <br /> 2. ❑ A Sanitary Permit was previously issued. Permit# Date Issued <br /> 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. <br /> 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. ®Conventional b. ❑ Alternative c. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. ® Seepage Bed b. ❑See a e Trench c. ❑Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> 3 4.10 4.10 95.4 Feet ®Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY pSite <br /> in allons Total #ot Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App' <br /> TanTanks strutted <br /> ks <br /> Septic Tank or Holding Tank 100h 1000 1 F WIESER'S ❑ <br /> Lift Pump Tank/Siphon Chamber ER'S 21 El I ❑ El I ❑ I LJ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> ARLYN J. HELM 3360 715 635 7595 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> P-0-BOX 71. SPOONER WI 54.801 <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> SADE 3331 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved JSanitary Permit Fee Grountlwater ate IssuisgAgenl Signature(No Stamps) <br /> Approved ❑ Owner Given Initial /,�y(A� Surchaiggq:,p.rr,e yy� <br /> Adverse DeterminationJf 60."" "'U4 ) <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />