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SANITARY PERMIT APPLICATION <br /> =moi i i o <br /> In accord with ILHR 83.05,Wis. Adm. Code cNTv w^fie <br /> STANITA�;�Y PERM <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than Ve — J �� L�� <br /> 8'%x 11 Inches In size. E Check if revision to previous application <br /> —See reverse side for Instructions for completing this application. ST TE PLAN I.D.NUMBER/ <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. 1--b -S <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Ladonna Lyon '/4 /4, S T 38 , N R18 Wor) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# K# <br /> RR #1 Box 228 14 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Hinckley, NN 55037 612 84-6220 North Shore Island View S division <br /> Lml CITY 11. TYPE OF BUILDING: (Check one) ❑State Owned VI AGE NEA EST ROAD <br /> Wood River No h Shore Drive <br /> ❑ Public ®1 or 2 Fam. Dwelling—#of bedrooms2 PAR EL TAX NUM ER( ) <br /> 111. BUILDING USE: (If building type is public,check all that apply) O _ I\ r— _oc�-Hoc <br /> 1 ❑ Apt/Condo O� <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Ou door Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Set vice Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Otter: 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 ❑ 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 DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERI.RATE SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 NA NA NA NA NA Feet NA Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Sept cTank or HoldinTank 2,00 -- 2,000 1 1 Skaw R <br /> I Ll <br /> Lift Pum Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached Aans. <br /> Plumber's Name(Print): Plumber's Signature,(No Stamps) MP/MPRSWNo.: Business Phone Number: <br /> Wade Rufsholm 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 Per t Fee(Includes Groundwater a e ssue Issuing t net e o m s) <br /> req} �u harm Fee) _ <br /> Approved ❑ Owner Given Initial 1�1� �S�`u <br /> Adverse Determination 3� ll <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,O ner,Plumber <br />