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== SANITARY PERMIT APPLICATION <br /> COUNrY, 1 1 <br /> In accord with ILHR 83.05,Wis.Adm.Code , \ <br /> STATE SANT RY PERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than L�s6q) a�C, l <br /> 8'%x 11 inches in size. �f <br /> Check if revision to previous application <br /> —See reverse side for Instructions for Completing this application. STA E PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTYOWNER PROPERTY LOCATION <br /> Mark & lisa Anderson t/4 %, S24 T40 , N, R 17 EK(or)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCIf#/ L <br /> 2413 150th Street 6 �� <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Luck, WI 54853 CSM Vol. 14, Pg. 24 <br /> II. TYPE OF BUILDING: (Check one) 10 CITY : NEAR ST ROAD <br /> ❑State Owned Fj VILLAGENo <br /> Dn1oII So th Shore Drive <br /> ❑ Public ®1 or 2 Fam. Dwelling,#of bedrooms PARCEL TAX NUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) Q��.�LNOLf — C"1 ' <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> El Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Res aurant/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. 0 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of I 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 /> 300 429 1 432 .69 NA 1 97 Feet 99.4 Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #ot Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank Skew <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 plans. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) r <br /> /MPRSW No.: Business Phone Number: <br /> Wade Rufsholm C�ct � 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> P.O. Box 514 24702 Lind Road Siren, Wl 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> I�/ ❑ Disapproved Sanitary Per it Fas(includes Groundwater Date ssue Issuing t ignatu N amps) <br /> u!V A roved Suryyy��ry��'rge Fee) <br /> 77 PP ❑ Owner Givan Initial j 167 <br /> _i�t-�\� <br /> Adverse Determination U (� 'h' <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.0"3) DISTRIBUTION: Original to County,One Copy To:Safety8 Buildings Division,Owner,Plumber <br />_ i _ <br />