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Safety and Buildings Division <br /> QFC i SANITARY PERMIT APPLICATION Bureau of Building water Systems <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83 05,Wis.Adm.Code P.O.Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8112 x 11 inches in size. Burne`A <br /> • See reverse side for instructions for completing this application State Sanitypermtt5N15mtuber <br /> The information you provide may be used by other government agency programs L]check it revision tope ilius application <br /> I Privacy Law,s. 1 5.04(1)(m)1. <br /> State Plan LD.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION S96-20694 <br /> Property Owner Name Property Location <br /> Robert Garin 11 1/4 1/4,S22 T37 N, R18 A/00W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> na <br /> 5344 Anderlie Lane 5 <br /> City,State Zi Code Phone Number Subdivision Name or CSM Number <br /> White Bear Lake MN 5110 (612 ) 653-1040 Dennis Pine Lake Subdivision <br /> II. TYPE OFBUILDING: (check one) [j State Owned ElIty Nearest Road <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms El village <br /> E] Publicgj Town OF Trade Lake Pine Lake Rd <br /> 111• BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 034 - 9015 - 01 500 <br /> 1 ❑ Apartment/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 box on line A. Check box online B, if applicable) <br /> A) 1. Q New 2. ❑ Replacement 3 ❑ Replacement of q ❑ Reconnection of S ❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number 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 410 Holding Tank <br /> 12❑Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 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 /> 300 Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> na na na na holdino t9W1 Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab coy- Fiber- Plastic Exper <br /> NewtExistingGallons Tanks Concrete steel glass App. <br /> TanksTanks strutted <br /> Septic Tank or Holding Tank 2000 - 2000 1 Wieser Concrete ® ❑ ❑ 1:1 ❑ ❑ <br /> I ift Pump Tank/Siphon Chamber ❑ ❑ I ❑ 1 ❑ 1 ❑ ❑ <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) amps) MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels P bei gnat (tyo MP 330 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code). <br /> PO Box 315 Siren Wl 54872 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> El Disapproved Sanitary Permit Fe (includes Groundwater Date Issued Issuinnature am s) <br /> roved / .5-5 surcharge reel /_ /�G <br /> r'�App []Owner Given Ic]Cl � <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SHO-6398(R.05/90 MTRIBUTION. Originalm CnurJ y,One copy To: SafetyBHuildin,Dienipn,0-neq Plu.F , <br />