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ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couNTv <br /> _ U CA - <br /> —`moEms w STATE SANRA YPERMIT#j1/_o <br /> log <br /> -Attach complete plans( the county copy only)for the system,on paper not less than ❑ 175 7 I U <br /> 8%x 11 inches in size. heck it reonto 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 /> Kwit and Diane Ua b 1,'/4, S 7 T 40 , N, R 16 JE((orPROPERTY OWNER'S MAILIN ADDRESS 1230 Dwane StAeet CITY,STATE ZIP CODE PHONE NUMBER ON NAME OR CSM NUMBER <br /> South St. PauE MN 55109 11 P . 286 <br /> 11. TYPE OF BUILDING: Checkone) NEARESTROAD <br /> State Owned GE: Ualz2and East yeftow Rive Road <br /> ❑ Public ©1 0 2 Fam. Dwelling-#of bedrooms 2 <br /> III. BUILDING USE: (If building type is public,check all that apply) - 7-�' 7-0 1- /40 <br /> 1 ElApt/Condo cz <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: (C eck 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 / II , /I Existing System <br /> B) ® A Sanitary Permit was previously issued. Permit# 1[%_7_7q Date Issued q-1`f -2O <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 H Seepage Bed 21 El 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 13,ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> R OUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/dayIaq.ff.) (Min./Inch) ELEVATION <br /> 300 410 432 .7 2 1 96.7 Feet 99.2 Feet <br /> VICAPACITY I. TANK Site Fiber- Exper. <br /> N <br /> INFORMATION ingallons Total #of Prefab.ew isti Gallons Tanks Manufacturer's Name ConcreteCon- Steel glass Plastic App <br /> Tanks I Tanks strutted <br /> Septic Tank or Holdino Tank 800 800 1 1 Skaw <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): Plumber's Signature:(No mps) MP/MPRSWNo.: Business Phone Number: <br /> Wade RuUzhorn 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.U. Box 514 S Aen (UI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater ate,Issued Isau' g A nt Sign r (No Stamps) <br /> Approved ❑ Surcharge Fee) <br /> Owner Gi en Initial ,H I�n•� <br /> A v rmin e t 33 ✓V -Y <br /> X. CONDITIONS OF APP ROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.1 I88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />