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�ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> �M�•�_� STATES NITARI�RMIT#�$Firl� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than t v, <br /> 8'b x 11 inches in size. ❑ Check If r� 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 LOC TION <br /> Chad PedeA,5on JJ(JI y. /a, S 22 T N, R 19 E(or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 14128 Bloom Road <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> GnantzbuAg, WI 54840 715 463-5797 pct. NW 114 SW 114 <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned VILLAGE(tu McUcehkand Bkoom Road <br /> ❑ Public ®1 or 2 Fam. Dwelling,#of bedrooms 2 M IF OF <br /> AX NUM <br /> 111. BUILDING USE: (If building type is public,check all that apply) 040-3622-02 200 <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. ❑x 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 72.ABSORP.AREA 13.ABSORP.AREA 14. LOADINGRATE 5. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 480 480 .63 <3 1 97.5 Feet 100.0 Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #Of Prefab. Fiber- App. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 750 -1750 1 1 Max TMC <br /> Litt Pump 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:(N tamps) �y MP/MPRSW No.: Business Phone Number: <br /> Wade Rubehotm 3367 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.U. Box 514 Sihen, WI 54872 <br /> IX. OUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sani(ary Permit Fee(Includes Groundwater a e issue Issuing Agent S' natu (No S s) <br /> surcharge Fee) ^ /] <br /> Approved ❑ Owner Given Initial ,-qK�, -.Gl (./1 �Si <br /> Adverse Determination <br /> C NDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />