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SANITARY PERMIT APPLICATION <br /> ra In accord with ILHR 83.05,Wis.Adm.Code couNTv <br /> e <br /> STATE SANITAR���(((PERMIT# p <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ C��� T# I� <br /> 8%x 11 Inches In size. Check if revi onto previous application Q <br /> —See reverse side for IDStrUCtlOns for completing this 8ppIICa[IOn. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER 1 PROPERTY LOCATION <br /> Mark Heverly 1/4 <br /> Y4, S 20 T 40 N. R 14 FX(or)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# \ <br /> 2279 Segundo Court, #4 7 <br /> CITY,STATE ZIPCODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Pleasanton, CA 94588 510 62-6280 Oak La Addition 1 <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned ❑ VILLAGE <br /> 10 TOWN OF: Sent <br /> ❑ Public Count Road A <br /> ®1 or 2 Fam. Dwelling-#Of bedrooms� PARCEL TAX NUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) (:�t74 ^qC)o <br /> 1 ❑ Apt/Condo t <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranUBar/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. ® 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 3.ABSORP.AREA 4. LOADING RATE 5. FERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 450 643 648 .69 NA 96.6 Feet 99 Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New istin Gallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank1 11,000 kap <br /> Lift Pump Tank/Siphon Chamber 600 600 <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:( tamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Rufsholm � 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.O. Boa 514 Siren, WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee includes Groundwater Date IssuedIssui A nt Signa ( Sta ps) <br /> Approved ❑ Owner Given Initial �1y}-� charge Fee) '(j <br /> Adverse Date rmin tion -�T 1�� —'�-� 1 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />