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SANITARY PERMIT APPLICATION COUNTY <br /> DILHR <br /> MEMNONIn accord with ILHR 83.05,Wis.Adm.Code <br /> �}lJl. f 1GCil� p <br /> •��- STAT SANITARY ERMIT# 1DeI <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ��(��73 <br /> 834 x 11 inches in size. ❑ Check if revisi o 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 /> Jamey J. Ut son '/4 '/4,S 30 T41 , N, R 15 E (or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK 0 <br /> 3300 Dana Dnive 36 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> BUAluviPte, MN 55337 612 890-7889 Furet Addition to Sema Lea Amey <br /> It. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> El Owned VILLAGE: SW _6,6 W. Buntingame Lake Road <br /> TnWN OF <br /> [] Public ®1 or 2 Fam.Dwelling-#of bedrooms 3 PARCELTAX BER <br /> Ill. BUILDING USE: (If building type is public,check all that apply) — <br /> 23 <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. TYIIPPE�E OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. L3 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 DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 8. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.K.) (Min./inch) ELEVATION <br /> 450 720 720 .63 2 94.9 Feet 97 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total of <br /> Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Hold i no Tank 7 <br /> Lift Pump Tank/Siphon Chamber <br /> Vlll. 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:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Ru4hhotm 1 1 3361 775 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.U. Box 574 Sihen, WI 54872 <br /> M. COUNTYIDEPA RTMENT USE ONLY <br /> ❑ Disapproved SanitaryPermit Fee(Includes Groundwater as ssue Issuing Age gnat ( tamps) <br /> Surcharge Fee) –Q9 <br /> Approved F-1Owner Given Initial �` <br /> Adverse Determination <br /> vV <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />