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SANITARY PERMIT APPLICATION <br /> 751LHR In accord with ILHR 83.05,Wis.Adm.Code coullry <br /> STA SANITA'Y PER IT ` <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ❑ (� O <br /> 8'%x 11 inches in size. heck If revision to previous application <br /> –See reverse side for Instructions for Completing this application. STAIE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Shawn Dewey Y. SC'/a,S 17 T 40 , N, 14 R(or)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOC # <br /> 2830 Augustine Road <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Webster, WI 54893 715 635-3555 pcl. SW SE <br /> If. TYPE OF BUILDING: (Check one) ❑State Owned 0 CITY <br /> VILLAGE: NEAR T ROAD <br /> Scott Au stine Rd. <br /> ❑ Public ®1 or 2 Fam.Dwelling-#of bedrooms 3 ) <br /> 111. BUILDING USE: (If building type is public,check all that apply) � - LI t " _ 01 q(x <br /> 1 F-1 Apt/Condo <br /> �At <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Rest urant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Sery ce Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYfPPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. gL J 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 ❑ SpecityType 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 12.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 450 REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 643 648 .69 NA 97.9 Feet 100.1 Feet <br /> VII. TANK CAPACITY Site <br /> INFORMATION in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> New istin Gallons Tanks oncret strutted glass App' <br /> Tanks Tanks <br /> Se tic Tank orHoldin Tank 1,00 -- 1,000 1 Skew <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 pi ins. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Rufsholm /r — 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.O. Box 514 Siren, WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date sau Issuing ge I g atur N Ste a) <br /> Approved ❑ Owner Given Initial rI \ siaanarge Fee) <br /> Adverse De rmin ' L <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,Own r,Plumber <br />