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SANITARY PERMIT APPLICATION <br /> DIL IR In accord with ILHR 83.05,Wis.Adm.Code COUNTYT n <br /> • � STATES NITARYP MIT#a07� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than �'35 <br /> 8'%x 11 inches In size. ❑ Check if revialon 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. — S <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Dake U. Andenaon SW Y4 SW '/4, S 4 T 37 , N, R 18 E(or)AQ <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 72150 M-y Road <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> G)tant6buA , WI 54840 715 488-2793 <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned vaucE Tnade Lake M-Y Road <br /> ❑ Public ❑1 or 2 Fam.Dwelling-{k of bedrooms e <br /> III. BUILDING USE: (If building type is public,check all that apply) — 1 ,�r�jy— Oa <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. 0 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. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 NA NA NA NA NA Feet NA Feet <br /> VII. TANK CAPACITY 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 strutted <br /> Se tic Tank or Holdino Tank 2,001 --- 12,000 1 1 1 Skaw I Ll <br /> Litt Pum 7ank/SI 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:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Ru{ishokm �' i 3361 775 349-7286 <br /> Plumber's Address(Street,City,State,ZIP Code): <br /> 24702 Lind Road P.U. Box 514 Suten, WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved SanitaryPermit Fee(Includes eaGroun water Date Issued Issuing Agent Sin a( tam <br /> Approved <br /> El Given Initial dt Ia,.,^ <br /> AdvisrseDeternn'ruttion <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,Owner,Plumber <br />