Laserfiche WebLink
SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. CodeSTACOUNTY <br /> ❑ey\ITAfiV PERMIT xO <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than I O Jt <br /> 8'F 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 /> Donald Hokanson /4 /4, S 20 T40 , N, R 16 1 (or)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 7679 Prospect Avenue 11 1 1 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Danbury, WI 54830 715 866-7168 Village of Yellow Lake Assessor's Plat <br /> I1. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned O VILLAGE <br /> ❑ Public ®1 or 2 Fam. Dwelling #of bed rooms Pros ect Avenue <br /> PAR EL TAX NUMBER(^) r <br /> III. BUILDING USE: (If building type is public,check all that apply) /^,_.vt 1 X�_ C) ^ I r, v ) <br /> 1 ElApUCondo <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 E�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 7 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 500 504 .59 KA 95.5 Feet 99.4 Feet <br /> VII. TANK CAPACITYin gallons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or HoldingTank BOD -- 800 1 Skaw <br /> Lift Pum 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): Plumbers Signature:(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Rufsholm '< G•— - � 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.O. Box 514 Siren WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwaterae IssuedIssui Agent Sign ure(No tamps) <br /> DAroved I60Sur ergs Feel <br /> pproved Given Initialcx-i �_� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SB66398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />