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SANITARY PERMIT APPLICATION <br /> E <br /> HR In accord with ILHR 83.05,Wis.Adm.Code co NTv <br /> urnett <br /> ST SANIRYPERM\IT# 1 <br /> — Attach complete plans(to the county copy only)for the system,on paper not less than i�p�� t? <br /> 8%x 11 Inches In size. 1:1Check if revision to 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. GL 5'.4 <br /> PROPE <br /> JjnFPR R PROPERTY LOCATION <br /> ALBRECHT '/4 1/4, S35 T 38 , N, R 15 N4r)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 4705 SUNNYSIDE RD 3 <br /> CITY,STATE ZIPCODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> EDINA MN 1 55424 612 926-9901 1 <br /> 2 <br /> Mpq 148 Vol 2 <br /> II. TYPE OF BUILDING: (Check one) in CNEA EST ROAD <br /> s State Owned PARCELTAX NIN VILLAGE: Johnson Rd <br /> ❑ Public El or 2 Fam. Dwelling,#of bedrooms 2 UM R( )ette <br /> III. BUILDING USE: (If building type is public,check all that apply) 14 2235 02 100 <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 ❑ Re taurant/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 Bit applicable) <br /> A) 1. 0 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 PE77 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6 SYSTEM ELEV. 7. FINAL GRADE <br /> 3DD REQUIRED AREA <br /> ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 429 432 .7 nd 99.65 Feet 1 102• Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 1 750 1 Wieser Concrel-e— El F-1 1-1 F-1 <br /> Lift Pum Tank/Si hon 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): MP/MPRSW No.: Business Phone Number: <br /> PI bar's Sign tura:( o Stamps) <br /> DONALD DANIELS MP 330 715 349-5533 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> PO BOX 316 SIREN WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> r�-� ❑ Disapproved SanitaryP rmn Fee(Includw Groundwater a issuedIssuing IS' a e N tamps) <br /> II Y Approved ❑ Owner Given Initial ���(���5'�{`�a'(�arge Fee) €T �. <br /> T Adverse Determination <br /> I�' v <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,O ner,Plumber <br />