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&I <br /> 'jl l / <br /> IF '911k SANITARY PERMIT APPLICATION`Iii �� <br /> � � In accord with ILHR 83.05,Wis. Adm. Code cou "al <br /> r <br /> h6 <br /> RY PERMIT t # <br /> —AttacSTA E SAN1I <br /> h complete plans(to the county copy only)for the system,on paper not less than —N 4`1 vjey <br /> 8'fixll inches In size. heckif evisiontoprevious application C<D <br /> —See reverse side for Instructions for Completing this application. STA' E PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> RT SU4D5_r90" '/4 '/4, S T N, I E(oCW) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOC # <br /> (0331 $L..R I S'vELL AV. S 14 <br /> CITY,STATE I ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUM ER <br /> KI�NFIELA MN Z ( Iz aw- D <br /> II. TYPE OF BUILDING: (Check one) CITY NEAR ST ROAD <br /> State Owned VILLAGE V . )q v_ <br /> ❑ Public or 2 Fam.Dwelling—#of bedrooms PA ELTAX NUM (S) R <br /> III. BUILDING USE: (If building type is public,check all that apply) ;�0-g335 <br /> 1 ❑ ApVCondo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 Merchandise: Sales/Repairs 11 ❑ Res W <br /> ar/Dining <br /> 4 Church/School Mobile Home Park ❑ Se )n/Car Wash <br /> 5 Hotel/Motel Offi a ry y <br /> TYPE OF PERMIT: y one in n if enable) <br /> A) <br /> A) 1�Newla e t lacement of • nnection of 5.El Repair of an <br /> System to Tank O y xis ng System Existing System <br /> B) El Sanitary Pe w p vl\\i U sued. Perm Date Issued <br /> V. TYPE OF SYSTEM: C only Rko <br /> Non-Pressurized Distribu ' Pre butip� ental Other <br /> 11 Seepage B 00pecify Type 41 ❑ Holding Tank <br /> 12 Seepage rench In- /VT 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit �9 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 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED AREA <br /> ft.) P OPOSSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Q ELEVATION <br /> LIST` 3 Q ( — -- "� Feet 1 ( . ! Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App. <br /> Tanks Tanks structed <br /> Septic Tank or Holdin Tank Q <br /> Lift Pum Tank/Siphon Chamber <br /> Vlll. 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): PlumbeLsS�ign�ature:IN St psI MP/MPRSWNo.: Business Phone Number: <br /> ICffARn KI S I _ d 3 qz-6 ( 315 ) 966- 1157 <br /> lumber's Address(Street,City,State,Zip Code <br /> Z (Do ,� 35 t,J sr�R U . S�f8R3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Pk <br /> ❑ Disapproved Sanitary Permit Fee(lncludwGroundwater ae issuedIssuin Ag nt Signa[ re oS mps) <br /> W Approved ❑ Owner Given Initial \ „-- Sur rge Fae) � <br /> //�� Adverse Determination YI Jl <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Ow er,Plumber 19 <br />