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- mm" IllSANITARY PERMIT APPLICATION COUNTY <br /> DILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITAR{PERMIT#)88o 1 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ ��'�Q3) <br /> 881/2x 11 inches in size. Check if rev ion to previous application <br /> —See reverse side for Instructions for completing this application. STATE PLAN I .NUMBER <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Ken Ta .fan NW '/4 SE '/4,S 5 T 38 , N, R 15 E (or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 255 E. KeK�a X501 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> St. paut, MN 1 55101 612 91-7492 Li <br /> it. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> Ll Owned VILLAGE' Lal&ttette WanneA Lake Road <br /> ❑ Public ©1 or 2 Fam.Dwelling—#of bedrooms 2 OAAEF <br /> Cjj111. BUILDING USE: (If building type is public,check all that apply) 01-3—C20-0 <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. El New 2. ® Replacement 3. EJ 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 H 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 4. LOADING RATE 15. PER' RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ff.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 480 480 .63 4 92.6 Feet 95 Feet <br /> CAPACITY Site <br /> VII. TANK in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION �Nevv istin Gallons Tanks Manufacturer's Name ConcreteCon- Steel glass Plastic App <br /> strutted <br /> ks Tanks <br /> -TT-==-TT- <br /> Septic Tank or Holding Tank 0 --- 00 <br /> Lia Pump Tank/Siphon 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 mps) PRSW No.: Business Phone Number: <br /> Wade Rubhhotm �i(d e_ MP/M3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.O.b ox 514 SaAen WI 54872 <br /> XJX. COUNTY/DEPARTMENT USE ONLYDisapproved Sanitary Permit Fee(Inclutlee Groundwater❑ Surcharge Feeproved ❑ Owner Given Initial 4I I�C- i�?1 L <br /> Advers Determination <br /> QLD J lel <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />