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00001 <br /> 0�ILHR SANITARY PERMIT APPLICATION couNTV <br /> I_HR In accord with ILHR 83.05,Wis.Adm.Code LZNL,�r <br /> STATES_ANIITTARYP RMIT#;zur,33 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8%x 11 inches in size. ❑ Check irrevision 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 /> Cant Gna henteen AAE 144E'/4,S 26 T39 r N. R 16 E (or)&Q <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 6247 Peteneon Road <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Webhten, W7 54893 715 866-7913 pct. NE NF <br /> 0 CITY <br /> 11. TYPE OF BUILDING: (Check one) ❑State Owned ❑ VILLAGE NEAREST ROAD <br /> 10 TOWN F� Meenon Peteneon Road <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms Z FAKUFL TAX N <br /> 111. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo <br /> 2 El Assembly Hall 6 El Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Ear/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-fn-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 12.ABSORP.AREA 3.ABSORP.AREA 14. 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 /> 300 480 1 480 .63 4 96-3 Feet 99. 1 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total of Manufacturer's Name Prera9, Con- Steel Fiber- plastic Exper. <br /> INFORMATION New istin Gallons Tanks oncret glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank 00 800 1 Skald <br /> Lift Pump Tank/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 ignature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade RuAzhotm ZZ,, 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.U. Box 514 SiAen, GUI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Lj Disapproved Sanitary Permit Fee(Includes Groundwater a essu Issuing A Sign lure(N Stamps) <br /> Approved E] Owner Given initial I�� surcharge Fee) n <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/89) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />