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SANITARY PERMIT APPLICATIONISTATE <br /> OILHR In accord with ILHR 83.05,Wis.Adm.CodeURNETr <br /> NITARYP MIT#'lGIO� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than � Oil if revision revious applicatioi <br /> 8%x 11 Inches In size. AN I.D.N MBER <br /> -See reverse side for instructions for completing this application. <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. t. (� <br /> PROPERTY OWNER PROPERTYLOCATION W <br /> NW %SW %,S 10 T39 , N, R 14 <br /> ,T nir LOT# BLOCK# <br /> PROPERTY OWNER'S MAILING ADDRESS NA <br /> 2143 Count Rd. G Fire 2143 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER Vf+CCn I V. <br /> S ner 54801 1715- 635-7011 clTr NEAREST ROAD <br /> if. TYPE OF BUILDING: (Check one) LJ state Owned vIL1AGE: Rusk county rd. a <br /> [] Public 91 or 2 Fam.Dwelling-#of bedrooms 1 RET u ER ) yy <br /> 111. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo 10 ❑ Outdoor Recreational Facility <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 11 ❑ Restaurant/Bar/Dining El Campground 7 ❑ Merchandise: Sales/Repairs 12 ❑ Service Station/Car Wash <br /> 4 ElChurch/School 8 ❑ Mobile Home Park 13 ❑ Other: Specify <br /> 5 ElHotel/Motel 9 ❑ Office/Factory <br /> IV. TYPE OF PERMIT: (Checnk only one in line A. Check line B if applicable) EJ Repair of an <br /> A) 1 ❑ New 2. 0 Replacement 3. 0 Tank Replacement of 4 ❑ Reconnection <br /> z s nn S(stem � Existing System <br /> System System state 43539 <br /> Date Issued o� <br /> B) IadcA Sanitary Permit was previously issued. Permit# <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Other <br /> Non-Pressurized Distribution Pressurized Distribution Experimental 41 El Holding Tank <br /> 21 ❑ Mound 30 ❑ Specify Type <br /> 11 Seepage Bed 42 ❑ Pit Privy <br /> 12 LJ Seepage Trench 22 ❑ In-Ground 43 ❑ Vault Privy <br /> 13 ❑ Seepage Pit Pressure <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> Min./Inch) ELEVATI( <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABS S P.(a 4. LOADING RATE 5.PER' RATE 6. SYSTEM ELEV. 7. FINAL G <br /> REQUIRED(sq.ft.) <br /> PROPOSED(sq.tt.) (G�s/day/sq.tt.) (Min <br /> 95.2 Feet ` '�"i r <br /> 450 643 648 <br /> CAPACITY Prefab. Site Fiber- Ex <br /> VII. TANK in allons Total #of Manufacturer's NameCon- Steel glass Plastic A <br /> INFORMATION New isti Gallons Tanks oncret structed <br /> Tanks Tanks <br /> Se tic Tankor Holdin Tank <br /> Litt Pum Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached pla Business Phone Number: <br /> Plu is Signature:(No Stamps) MPIMPRSW No.: <br /> Plumber's Name(Print): �f MP 6290 715-135-8752 <br /> Richard G Anderson �✓ �rF/U 2' <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Rt. 1 Box 1516 Spooner, WI 54801 <br /> CO UNTYIDEPARTMENT USE ONLY Iss g gent Sign (No Stamps) <br /> Disapproved SanitaryPerm it Fee(Includes Groundwater e ;=Ue <br /> Surcharge Feel <br /> Approved ❑ Owner Given Initial 26 aD <br /> Adverse Determin ion <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to county,One Copy To:Safety&Buildings Division,Owner,Plumber <br />