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DIL.HR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> • _ STATE SANITARY KRMIT#aQ 7a a <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ /1 i <br /> 8'%x11inchesinsize. kif vlsio 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. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Danne22 Schuttz SW 'X SE %,S 14 T 40 , N, R 17 IR(Or6l <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 1007 Robinhood Place 2 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NA E OR CSM NUMBER /n� <br /> Shaneview, MN 55126 612 483-6175 05 r r • � a- i/1 Q- v 4-, L-c�T <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned w aU Union Johvv on Lane <br /> ❑ Public ❑x 1 or 2 Fam. Dwelling-#of bedrooms1_ PARCEL TAX NUMBER(S) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) — �' — U� `(-,C)CD <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. ® 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 ❑ SpecifyType 41 ❑ Holding Tank <br /> 12 H 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 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 410 432 .69 4 99 Feet 102 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 strutted <br /> Septic Tank or Holdina Tank 1 Skaw <br /> Litt 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) MP/MPRSW No.: Business Phone Number: <br /> Wade Ru6zhotm �cac�- 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,ZIP Code): <br /> 24702 Lind Road P.U. Box 514 Sin n, (UI 54872 <br /> I COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e ssu Iss ' g pent Signet o Stamps) <br /> Approved ❑ Owner Given InitialSurcharge Fee) , <br /> A v D t rmination <br /> 135 a� -io 9 <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 8 Buildings Division,Owner,Plumber <br />