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SANITARY PERMIT APPLICATION COUN r <br /> 7DILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> s• � STATE SANITAR ERMIT#1 0ND <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than (1104 �J l <br /> 834 x 11 inches in size. ❑ Check If revisi to 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. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Jamey Kody qF %4 NF %,S 18 T 38 , N, R 15 E(or <br /> PROPERTY OWNER'S MAILING ADDRESS - LOT# BLOCK# <br /> 3308 W. 159th St <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Ctexetand, UN 44111 216 941-9004 <br /> It. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ❑ State Owned ❑ VILLAGE: LaFo ECette Dake Road <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms Z L A UFAMtKitil <br /> III. BUILDING USE: (If building type is public,check all that apply) I -aa O- 0 400 <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. PERI.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 480 480 .63 4 97.6 Feet 100.2 Feet <br /> VII. TANK CAPACITY Site <br /> in ellons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank --- <br /> Lift Pum Tank/Siphon Chamber <br /> Vlll. 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 Ru&shotm (�q�1{ 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.U. Box 514 SiAen, W7 54872 <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> Li Sanitary Permit Fee(Includes Groundwater a e ssue Issuing a Sig re(No Stamps) <br /> Surcharge Fee) o n <br /> Approved ❑ Owner Given Initial <br /> Adverse D termination <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />