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DILHR SANITARY PERMIT APPLICATION , COUNTY <br /> o s In accord with ILHR 83.05,Wis.Adm. Code <br /> STATESANITA PERMIT#/ /'/yy <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> El <br /> ��� 7(J <br /> 8%x 11 inches in size. neck if ran to previous application <br /> -See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> DALE PETERSON NW %S W %, S 25 T 40, N, R 14/AIVrW <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> HCR59 1105 WEST POINT RD. Ajlkn 4_.• 07,31N/A <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> SPOONER. WI 54801 N/A <br /> 11. TYPE OF BUILDING: (Check one) ❑ State Owned L-I CITY <br /> ❑ VILLAGE NEAREST ROAD <br /> SCOTT WEST POINT <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms 2 LTAXNU ) <br /> III. BUILDING USE: (If building type is public,check all that apply) a I as_.Q f- <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreatlonal 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. ❑X 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 ❑x 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 /> V1. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAI 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. FERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 410 420 .71 3 93.7 keet 95.2 Feet <br /> VII. TANK CAPACITY Site <br /> in 11 Its Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New istin Gallons Tanks oncret glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank 00 00 1 SKAW <br /> Lift Pum Tank/Siphon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of he onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): lumber's SI natur No Stamps) r/MPRSW No.: Business Phone Number: <br /> MEL J, FERGUSON 3393 ( 715-135-7482 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> HCR59 BOX4 8d SPOONER WI 54 1 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date IssuedIssuing Agent 'gnature(No Stamps) <br /> Approved ❑ Owner Given Initial 1^�. o Surcharge Fee) 1�8-9 <br /> A Determination C6 , j <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />