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r.- . SANITARY PERMIT APPLICATION <br /> COUNTY <br /> TY <br /> In accord with ILHR 83.05,Wis.Adm.Code Burnett <br /> STA E SANT RY PERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than 1 ) <br /> 8'f,x 11 inches in size. <br /> 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 /> Diane S jobeck GL4 '/a Ya, S 3 5 T 38 , N, R 15 Ill W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 3510 Wid eon Way 1 na <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Eagan MN 1 55123 612 )653-2594 CSM VOL 2 l 184 <br /> Check one 11 CITY NEAR ST ROAD <br /> If. TYPE OF BUILDING: <br /> ( ) State Owned ❑ VILLAGE Johnson Rd <br /> ❑ Public x❑1 or 2 Fam. Dwelling—#of bedrooms 3 PARCEL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) 14 - 2235 - 01 900 <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 ❑ Res auranUBar/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 DAI 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 450 REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 643 648 .7 na 96.50 Feet 99.65 Feet <br /> VII. TANK CAPACITY ISite <br /> M_allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank <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): PI bar's Sig a[ure: o S s) MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels MP 330 715 349-5533 <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 ate Issued Issuing g i7na r IN mps) <br /> N.Aroved Surcharge Feel <br /> pp ❑ Owner Given Initial ��[� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety B Buildings Division,Ow er,Plumber <br />