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SANITARY PERMIT APPLICATION COUNTY <br /> 17— aassm%DILHR In accord with ILHR 83.05,Wis.Adm. Code <br /> RiirnpttSTATE SANITARY PER T# r32 S& <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ( 1 L1$1'S <br /> 8%x 11 inches in size. ❑ Check if revision to pr ious application <br /> -See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. S90-20048 <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Gary Marion NW '/4 SW %, S 28 T38 , N, R 15 )W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 3501 67th St. E. na I na <br /> CITY,STATE I ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> INver Grove Hts, 155076 1 ( 612- )457-4037 na <br /> ROAD <br /> II. TYPE OFBUILDIN (Check one) [:] StateOwned CITY <br /> LLLAGE LaFollette NEAREST& Styles Rd. <br /> JPAU OF' <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms 3 PA AX NUMBER(S) <br /> 111. BUILDING USE: (If building type is public,check all that apply) / �— r�v��v - �� C� o <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 ❑ 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 31 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERCRATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Feet 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 rank orHoldin Tank 1 -- 12000 1 1 TMC Inc- <br /> F <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): Plu rs Signature: mps) MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels <br /> Plumber's Address(Street,City,State,Zip Code): <br /> PO Box 316 Siren WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a a issuedIssui ant Signat e o Stamps) <br /> �Surcherge Fee) /� _ � <br /> Approved I Adverse Do❑ Owner Given Initial l�J\ �� /�1V/1 �. <br /> rmin ti bJ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />