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DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code 'L� r � <br /> m e [�(( I� <br /> STATE�ANITAR ERMIT# j�O � <br /> " <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 1:1 (/ J% <br /> 8%x 11 Inches In size. Cheek if rev' on 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 /> Duane Jackson M '% Np, %,S 34 T , N, R 18 E (o W ) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 11565 North Fork Dike Road <br /> CITY,STATE ZIPCODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Grantsburg, WI 54840 715 689-2213 <br /> 11. TYPE OF BUILDING: Check one) 1:1CITY NEAREST ROAD <br /> ( State Owned VILLAGE: St <br /> 4PAN RIF' Marshland North Fork Dike Road <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms 1 POARGEL TAX NUMBER(s) <br /> 111. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo JU `r V P�4J <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 ® 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 PEW7 2.ABSORP.AREA 13.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 /> 300480 -6 93.8 Feet 96.2 Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in gallons Total #ofPrefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank <br /> Litt Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> [,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) MP/MPRSW No.: Business Phone Number: <br /> Wade Rufsholm 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Co <br /> 24702 Lind Road P.O. Box 514 Siren, W1 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Ej Disapproved Sanitary Permit Fee(Includes Groundwater aessu Issuing gent ignatur oStamps) <br /> Approved ❑ Owner Given Initial �^ ffS't�)charge reel <br /> Adverse Determination ) �O 'I j�/2/9/ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6399(formerly Plb-67)(R.11/99) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />