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SANITARY PERMIT APPLICATION <br /> rZ U1 jLnHR In accord with ILHCOUNTYR 83.05,Wis.Adm. Code <br /> STATES NNI.T`A�RK�ERMIT# Lz;z <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than T yf } �� �� <br /> 8'f.x 11 inches in size. ❑ Check if revisi6n 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. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> NE '/4 NW '/4, S 14 T 40 , N, R 17 E (o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 310 W. 12th St. <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Haztin ,s, MN 1 55033 612 437-9521 c2. NE 114 NW 114 <br /> II. TYPE OF BUILDING: (Check one) ❑State Owned VILLAGE NEAREST ROAD <br /> l�II Union Count Road F <br /> El Public 01 or 2 Fam. Dwelling-#of bedrooms Z PARCEL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) 36 <br /> L�cl� --1-m <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. Q 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 PER 37 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 480 480 .6 2 96.7 Feet 99.7 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdin Tank <br /> Lift 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 Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Ru ahotm 1 1 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code <br /> 24702 Lind Road P.O. Box 514 S-iAen (UI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e ssue Issuing Agent Si nature No Stomps) <br /> usurcharge Fe) <br /> roved ❑ Owner Given Initial 0 <br /> _.J—0 A <br /> ��pp <br /> 0pp Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety8 Buildings Division,Owner,Plumber <br />