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�- °= SANITARY PERMIT APPLICATION <br /> "`"^ COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code JS�e1\ <br /> STATE SANITARY\PERMIT#dd�gga <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ (Y1 yd6, <br /> 8'%x 11 Inches In size. Check if revision 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 /> Ghe I)Qifts '/4 '/4, S 34 T 39 , N, R 19 IR(or)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 4246 Royce Stheet NE <br /> CITY,STATE MN ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Cotumbta Heights, 55421 pct. NW Nb <br /> If. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned VILLAGE We,5t MaA,5htan Spautd(n Road <br /> ❑ Public ❑X 1 or 2 Fam. Dwelling—#of bedrooms 2 PAR EL TAX NUM BER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) oyo-363y <br /> 1 ❑ ApVCondo <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 Bit applicable) <br /> A) 1. ❑X 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 HSeepage Bed 21 ❑ Mound 30 El SpecifyType 41 El HoldingTank <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 DAY 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 4000 480 .63 3 1 95.6 Feet 98 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 orHoldin Tank 750 --- 750 1 1 1 TMC <br /> Lift Pum Tank/Si hon 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:(Ntamps) MP/MPRSW No.: Business Phone Number: <br /> t <br /> Wade Rubshotm �/tJ act 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.O. Box 514 S{nen WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e Issued Issuing Agent Signature No St mps) <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial {f I S-O � `� _�O_�q <br /> Adverse Determination -E� l <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD6398(R.DB/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />