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�ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COGNTY <br /> STATE SANITARY� RMIT#(? 317 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than (h/ec <br /> 8'h x 11 inches in size. ❑ c k if revision 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. S - 3c�c, <br /> PROPERTY OWNER PROPERTY LOCATION <br /> JeAAy Nonwood '/4 Y4, S 16 T 37 , N, R 18 E(or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 11980 State Road 48 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> GAant-sbu.Ag, WI 54840 715 88-2411 pct. SE 1/4 SE 114 <br /> CITY NEAREST ROAD <br /> II. TYPE OF BUILDING: (Check one) ❑ State OwnedVILLAGE; Ir Lafie Hwy. 48 <br /> El Public E9for 2 Fam. Dwelling-#of bedrooms 3 AR Nu ( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) <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 n 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 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 450 ------- ------- ------- ----- ------ Feet --- Feet <br /> VII. TANK CAPACITY Site <br /> in al Ions Total #of Prefab. Fiber- Exper. <br /> INFORMATION New is8n Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdin Tankuuu aw <br /> Litt Pum 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 Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Ru65hotm 1 1 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.U. Box 514 Sinen, WI 54872 <br /> IX.,COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(in cludes Groundwater ae ssue Issui gent Signature(NoStamps) <br /> Surcharge Feel <br /> pprovad ❑ Owner Given Initial �(�� doff (�CJ <br /> Adverse Determination �) <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 />