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SANITARY PERMIT APPLICATION COUNTY <br /> 7DILHR In accord with ILHR 83.05,Wis.Adm. Code <br /> STATE SANITARY ERMIT#J&,%,;7 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than W07l <br /> 8'h x 11 inches in size. ❑ C eck if revisio 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 /> Dan Cove E'/4 >✓e'/4,S 20 T38 , N, R 17 E (or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 9837 State Road 70 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> SiAen, WI 54872 715 689-2317 pct. NE 114, NE 114 <br /> If. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ❑ State Owned wtuGE? DanteP,6 State Road 70 <br /> ❑ Public [ill or 2 Fam.Dwelling-#of bedrooms 3 A Nu ) <br /> III. BUILDING USE: (If building type is public,check all that apply) Q�—� c�. u— n , <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 Bit 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 PERDAY 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 /> 450 720 720 .63 4 1 104.5 Feet 107 Feet <br /> VII. TANK CAPACITY Site <br /> in alloIT Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 1 000 --- 11 .000 1 Skaw <br /> Lift Pump Tank/Siphon Chamber 600 600 1 <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 Signator (No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade RuUehoem o7 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.O. Bax 514 Siaen WI 54872 <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> p Disapproved I Sanitary Permit Fee(Includes Groundwater Rate Issued SS ng gent Sig a(No Stamps) <br /> Approved ❑ Owner Given Initial - - Surcharge Fee) <br /> AdverseDetermination (.r <br /> . CO DITIONS 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 />