Laserfiche WebLink
DILb-IR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couNTv <br /> • M� STATE SANITARY PERMIT# 1325S( <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ( i W -7-)0) <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 /> HAROLD KRAVCIK II NW +y,SW +/, S 15 T39 N, R 14 A"01r)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 26118 COUNTY IHI NA I NA <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> SPOONER, WI 54801 <br /> I1. TYPE OF BUILDING: (Check one) ❑State OwnedEJ CITY r <br /> VILLAGE' NEAREST ROAD <br /> 4E] TOWN OF _ <br /> 2USKT <br /> E] Public ®1 or 2 Fam. Dwelling–#of bedrooms 3— PAR ELTAX NUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) <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. 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 [J Seepage Bed 21 D Mound 30 ❑ Specify Type 41 0 Holding Tank <br /> 12 fl 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 PER71 2.ABSORP.AREA 13.ABSORP.AREA 14. 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 /> 450 615 615 NA <3 94. 0 Feet 96.0 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank WIESER S <br /> Litt Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the or#te sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plu bar's Signature,(No Os) MP/MPRSW No.: Business Phone Number: <br /> MELVIN J. FERGUSON 3393 715 635-7595 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> P.O.BOX 71, SPOONER, WI 54801 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ DIaeDOroved Sanitary Permit Fee(Includes Groundwater Date IssuedIs ing ent Signat o Stamps) <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial OC �(-5-90 <br /> Adverse Determination <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 />