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DILmmmml SANITARY PERMIT APPLICATION COUNTY rn <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> • _� STATES NITARY RMIT#n00%o <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than C)/o �I <br /> 8'%x 11 inches in size. ❑ Check if revisi 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 /> Lo /s Bei '/a %, S 26 T 38, N, R 18 E (or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 22989 County Road M <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Gnantsbuhg, (VI 1 54840 715 689-2479 pct. Gov. Lot 1 , <br /> It. TYPE OF BUILDING: (Check one LJ State Owned CITY NEAREST ROAD <br /> LLAGE Wwood Riveh Count Road M <br /> ❑ Public ©1 or 2 Fam.Dwelling-#of bedrooms R Nu ( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo 1111 <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. U 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 H Mound 30 El SpecifyType 41 El 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 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEMELEV. T FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 250 252 1 .2 4 1 98.9 Feet Mound Feet <br /> VII. TANK CAPACITY Site <br /> I n allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istm Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holdina Tank 1 ,0001 --- 11,0001 1 Skew <br /> 1,41 1 <br /> Lift Pum Tank/Si hon Chamber 600 - 1600 <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 Stamps) MPIMPRSW No.: Business Phone Number: <br /> Wade Ru6zho2m 1 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.U. Box 514 Siren, W1 54872 <br /> IX. POUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved Surcharge Fee) <br /> Sanitary Permit Fee(Includes Groundwater ae ssue Issuing Agent S' natur (No t ps) <br /> Approved ❑ Owner Given Initial �}�1 � g— <br /> Adve Determination �.0 o1 <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 />