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DILH I SANITARY PERMIT APPLICATION COUNTY& <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> - STATE SANITAR`,ERMIT#/810`.� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than El (j(�7(C6 <br /> 8%x 11 Inches In size. Check If revis n 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 /> Ra e h Lumtey NE '/4 NE '/4, S 22 T 40 N, R 14 E (Gr) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK if <br /> 1875 Countu Road A <br /> CITY,STATE ZIP CODE I PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> S oonen W1 1 54801 <br /> If. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned VILLAGE: Scott County Road A <br /> ❑ Public ❑X 1 or 2 Fam. Dwell ing-#of bedrooms 4 LTAx NUM <br /> III. BUILDING USE: (If building type is public,check all that apply) 93—/ qu;a — O) - /(D <br /> 1 ❑ Apt/Condo <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 PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 600 960 972 .62 2 95.3 Feet 98 Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in lions Total of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank 1200 - 11200 1 Skaw <br /> Litt Pump 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): Plumber's Signature:(No ps) MP/MPRSW No.: Business Phone Number: <br /> (Dade Rubhho& 1 1 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.U. Box 514 Sdnen, W1 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater I Date Issued Issuhtg-Agent Signatur 0o Stamps) <br /> F-1Surcharge Fee) , <br /> AApproved Owner Given Initial Q}/1�� /,f <br /> AdverseDetermination —t+ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />