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DILHR SANITARY PERMIT APPLICATION DOUNT1r <br /> In accord with ILHR 83.05,Wis.Adm.Code co <br /> STATE SANITAIYPERMIT#I955a3 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ ���((S <br /> 8'%x 11 inches in size. eck it rev n to previous application <br /> -See reverse side for instructions for completing this application. STATE PUN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> A2eene U'BAien SE t/4 SE ''/4, S 7 T39 , N, R 15 E (or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 5460 G"tyn Lake Road <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> WehteA, WI 54893 715 866-8664 <br /> 11. TYPE OF BUILDING: (Check one) El CITY NEAREST ROAD <br /> ❑ State owned VI GE: Sand Lake Gastyn lake Road <br /> ❑ Public ®1 or 2 Fam.Dwelling—#of bedrooms 3 ) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) a6- 3;07 C)S 1� <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. [y 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 H 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 13.ABSORP.AREA 14. LOADINGRATE 15. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.tt.) (Min./inch) ELEVATION <br /> 450 720 1 720 .63 4 89.8 Feet 93.7 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATIUM New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App. <br /> Tonka Tanks strutted <br /> Salic Tank or Holdino Tank <br /> Litt Pump 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: Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Ru{jaho2m tel✓ 3361 715 349-7286 <br /> Plumber's Address(Street,City,Stele,Zip Code): . <br /> 24702 Lind Road P.U. Box 514 SiAen, WI 54872 <br /> IX.,COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanit'�Lry Permit Fee(includes Oroundwner a e ssu Issuing A nl Sl nature ps) <br /> Approved ❑ Owner Given Initial m ' 'rte barge Fee) y� I <br /> Adverse rmin tl n J.P �J I <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />