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[� SANITARY PERMIT APPLICATION COUNTY <br /> LJ DILHR In accord with ILHR 83.05,Wis. Adm. Code (JT Burnett <br /> S"ITpis N`'I"AR 1313ERMIT# <br /> -Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I.D.NUMBER <br /> 8% x 11 inches in size. 87-04275-S <br /> -See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES [;] NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Eugene Becker NW % NW 1�a S 21 T38 , N, R 17 xF,(sayJ W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCKNUMBER SUBDIVISION NAME <br /> 1615 Spring na na na <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> Hastings, MN 55033 612 437-4308 0 VILLAGE : Daniels Mudhen Lake & HWy 70 <br /> 50 TOWNOF <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 2 OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4, if applicable) <br /> 1. a. ❑ New b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e.❑ Repair of an <br /> System System Septic Tank Only an Existing System Existing System <br /> 2. ❑ A Sanitary Permit was previously issued. Permit# Date Issued <br /> 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. <br /> 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. ❑Conventional b. 0 Alternative c. ❑ Experimental <br /> 2. a. ❑System- b. N] Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. ❑ seepage Bed b. ❑seepage Trench G. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> Feet ❑Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allcns Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or HoldingTank 000 2000 1 TMC Inc. ❑ x ❑ <br /> El <br /> Lift Pum Tank/Siphon Chamber _071=1= ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels �iiv ce �/ ��C_vLce�L� MP 330 715 49-5533 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> Box W Siren, WI 54872 same <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> Joan E. Daniels 3431 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> Box W Siren, WI 54872 715 349-5533 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater rNa_te_____j Iss g gent Signatu oStamps) <br /> Approved ❑ Owner Given Initialf/�f�l �r �t�� S rcharge Fee <br /> � _ G <br /> Adverse Determination w'JU �J' <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />