Laserfiche WebLink
SANITARY PERMIT APPLICATION <br /> 7DILI"IR In accord with ILHR 83.05,Wis.Adm.Code couN <br /> STATE SANITARY ERMIT#�1�qt (q <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ ���/ � T <br /> 8'%x11inches insize. c Ire 1otopreviousapplication <br /> -See reverse side for instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> DA. J. A. S ittet '% %, S 26 T 40 , N, R 15 ec(or <br /> PROPERTY OWNER'S MAILINGP DDRESS LOT# BLOCK# <br /> 614 Memniat Pa)thw 60"_ Lo-r <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Rocheatex MN 55902 501 282-6810 4 ,7 1 4 NE 1 4 <br /> II. TYPE OF BUILDING: (C eck one) ❑State Owned O VILLAGE NEAREST ROAD <br /> J c Lee4 Road <br /> ❑ Public ❑x 1 or2 Fam. Dwelling-{hof bedrooms 1 <br /> 111. BUILDING USE: (If builIng type is public,check all that apply) <br /> 1 El 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: (Ch k 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 Permi was previously issued. Permit# — Date Issued <br /> V. TYPE OF SYSTEM: (C heck 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 SYSTEN INFORMATION: <br /> 1.GALLONS PER DAY 2.A SORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> RE UIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 150 40 480 .32 4 95.5 Feet 97.8 Feet <br /> CAPACITY <br /> VII. TANK in allons Total #Of Prefab. Site Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdino Tank 750 - 750 1 WCP <br /> Lift Pum Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> ],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 Ru{ieho�m 61< 1� � 3361 715 349-7286 <br /> Plumber's Address(Street,City, tate,Zip Code): <br /> 24702 Lind Road P.U. Box 514 SiAen, (VI 54872 <br /> IX. COUNTY/DEPARTMEN USE ONLY <br /> Disapprove Sanitary Permit Fee(Includes Groundwater ate Issued Iss g gent Signet No Stamps) <br /> A I Approved ❑ Owner Determination <br /> et Initial .H Surcharge Feel �,� <br /> AdverseD rmin tin -�P <br /> X. CONDITIONS OF APPR VAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11108) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />