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SANITARY PERMIT APPLICATION CO JNTY <br /> 7 DILHR In accord with ILHR 83.05,Wis.Adm.Code Burnett <br /> STATE SANITARY P RMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8'h x 11 inches in size. E720103 <br /> -See reverse side for instructions for completing this application. PE ITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. Fo VARIANCE ❑YES D NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> James H. Quinehan GL2 SE '/4 NW '/4, S 21 T 37 , N, R 1 *YF W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME <br /> 9706 Foley Blvd. 12 na na <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST AD,LAKE OR LANDMARK <br /> Coon Rapids MN 55433 612 784-8940 ❑ VILLATOWNGE: Trade Lake Littl Trade Lake <br /> II. 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. x❑ 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 Agreeme it 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. U 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. ❑Seepage Trench C. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WA TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> Feet ❑P vale ❑Joint ❑ Public <br /> VI. TANK CAPACITY <br /> in allons Total #oT Prefab. Site Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Stee glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank <br /> Lift Pum Tank/Siphon Chamber ❑ <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 /> Donald Daniels / "'" ',Z2,Xeia 15 )349-5533 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> Box W Siren WT 54872 same <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> Joan E_ Danipls 3431 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Numb : <br /> Box W Siren, WI 54872 1 349-5533 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Sig ature(No Stamps) <br /> Approved ❑ Owner Given Initial 1 C� ,00 Surcharge Fee lb <br /> _1—R-7 <br /> Adverse Determination �Lr tyU as'(J� 6 �"yj <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD 6398(formerly Plb-67)(R.03/86) D'i.STRIBUTIONOriginal to County,One Copy To.Bureau of Plumbing,Owner,Plumber <br />