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SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis. Adm. Code +TE <br /> STATE SANITARY MIT# <br /> P <br /> Hilo <br /> —Attach complete plans (to the county copy only)for the system, on paper not less than STATE PLAN I.D.N07MBER <br /> 81/2 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 /> Ralph Kirk GL8 '/4 %, S 25 T 38 , N, R 18 EX=) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> 9009 35th Ave N. na na na <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> New Hoe MN 55427 Im VILLAGE Wood River Little Wood Lake <br /> ll. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 3 <br /> OR ❑ Public(Specify): <br /> Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4, if applicable) <br /> 1. a. ❑ New b. ❑x 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. Q 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. ❑ Seepage 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 /> 615 630 99 .50 KI Private <br /> Feet ❑Joint El Public <br /> CAPACITY <br /> VI. TANK in allons Total #ot Prefab. Site Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 1000 1 1000 1 TMC Inc. 1 0 1 D Ll I ❑ <br /> Lift Pump Tank/Siphon Chamber 500 1 500 1 1 TMC Inc. I ❑ I ❑ ❑ I ❑ <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 /> Don Daniels MP330 715 349-5364 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> Box W Siren WI 54872 Same <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> Joan Daniels 3431 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> Box W. Siren, WI 48 2 715 349-5364 <br /> IX.. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved I S nary Permit Fee la..,, <br /> undwater ate Issuing Agent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial /n Aft rge Fee <br /> Adverse Determination (� LJ�J <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 />