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7ffItHR SANITARY PERMIT APPLICATION GOON r <br /> _ In accord with ILHR 83.05,Wis.Adm.Code <br /> �~ s• �� <br /> STATE -IT/pA�y Y PERMIT# 00 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �rp/o <br /> 8'%x11inches insize. Elif rev on 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 /> Can 2 to Schhank '/4 '/e,S 28 T 37 , N, R 18 E(or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK S <br /> 1574 Goth View Dnive <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Riven Fattz, (tlI 1 54022 715 25-5618 pct. G.L. 2 <br /> If. TYPE OF BUILDING: (Check one) El CITY NEAREST ROAD <br /> State Owned VILLAGE TAade Lake Count Road Z <br /> ❑ Public ©1 or 2 Fam.Dwelling-#of bedrooms PAR L uMt5tm(tSj <br /> III. BUILDING USE: (If building type is public,check all that apply) of22Y- /sAs- V C�—?C0 <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. Q 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 El 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. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 --------- -------- -------- ------- ------ ------- <br /> Feet Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank 2.0001 - 000 1 i Skaw <br /> Lift Pump Tank/ i hon 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 RuUahofm �ae(� 3361 It 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.O. Box 514 Siren (VI 54872 <br /> COUNTY/DEPARTMENT USE ONLY <br /> Disapproved �Sajnlry Permit Fee(IncludesGroundwater a slue Ise n AgentSig re(No Stamps) <br /> I�5 surcherge Fee)Approved ❑ Owner Given Initial <br /> Adverse Determination <br /> i 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 />