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SANITARY PERMIT APPLICATION <br /> 70ILH In accord with ILHR 83.05,Wis.Adm.Code couNTN <br /> ~�• STATE SANITA Y PERMIT#�1/ C�S 7 <br /> -Attach complete plan to the county copy only)for the system,on paper not less than C1770 b I <br /> 8'%x 11 inches in size ❑ Check If rev' Ion to previous application <br /> -See reverse side for I Structlons for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFOR ATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> GeoA e and ChaA WeidendoAA % ''/4, S 7 T 40 , N, R 16 WOr W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT III BLOCK# <br /> 31270 Jackson Road NE <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Canbnld e MN 55008 612 689-3369 R<veh Oaks Subdivision <br /> 0 CITY <br /> 11. TYPE OF BUILDING (Check one) ❑State Owned ❑ VILLAGE: NEAREST ROAD <br /> Ualz2and West YePCaw Riven Road <br /> ❑ Public 9:11 or 2 Fam. Dwelling-#of bedrooms 2 PARCEL <br /> III. BUILDING USE: (If building type is public,check all that apply) cz <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/Scho 1 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 Be 21 ❑ Mound 30 EJ Specify Type 41 EJ Holding Tank <br /> 12 ❑ Seepage Tre ich 22 ❑ In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fil I <br /> VI. ABSORPTION SYS EM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gala/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 480 480 .63 4 94. 1 Feet 96 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdina Tan <br /> Lift Pump Tank/Siphon Char nber <br /> Vlll. RESPONSIBILrn STATEMENT <br /> I,the undersigned,assu no responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Business Phone Number: <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: <br /> (Dade Rubsha m vr/: � 3361 715 349-7286 <br /> Plumber's Address(Street, ity,State,Zip Code): <br /> 24702 Lind Roai P.U. Box 514 SiAen, WI 54872 <br /> IX.,COUNTY/DEPART WENT USE ONLY <br /> I Li Disapj rovedSa'n/itary Permit Fee(Includes Groundwater Date ssu I Ing gent Sig re(No Stamps) <br /> Approved ❑ Owne Given Initial q� I ryrsrcharge Fee) <br /> Adver is Determination <br /> X. CONDITIONS OFA RPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly PIb87)( .11/89) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />