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SANITARY PERMIT APPLICATION COUNTY <br /> V�A� In accord with ILHR 83.05,Wis.Adm.Code <br /> STA/TE SANITARY PERMIT Ill <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ,��(f��f��((��''`(�`�(��,%%, <br /> 8'fz X 11 inches in size. IJ Gneck if revision to previou i 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 /> Gary 6 Crickett Mackenzie '/4 '/4, S-ftl� 3T38 , N, R 14 f(or)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> P.O. Box 488 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Shell Lake, WI 54871 IV15 468-7052pcl. G. L. 1 6 8, 6 �l <br /> CITY : NEAREST ROAD <br /> IL TYPE OF BUILDING: (Check one) ❑State Owned ❑ VILLAGE Dewe Scenic View Lane <br /> ❑ Public ®1 or 2 Fam.Dwelling–#of bedrooms 3CEL AX NUMBER( ) <br /> III. BUILDING USE: (It building type is public,check all that apply) `'Q3 c\ , t co <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. El New 2. ® Replacement 3. El Replacement of 4. El Reconnection <br /> of 5.❑ Repair of a <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 ❑ HoldingTank <br /> 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Pri y <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. MRC.RATE <br /> E 6. SYSTEM ELEV. 7. FINAL ELEVATION <br /> GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) <br /> 450 642 648 .69 NA 1 96.2 Feet 98. 7 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> structed <br /> Tanks Tanks <br /> Septic Tank or HoldingTank 3500 — 1500 2 Skkaw % <br /> Lift Pum Tank/Siphon Chamber 633 -- 633 1 Skaw % <br /> Fj <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, tampsMP/MPRSW No.: Business Phone Num er: <br /> Wade Rufsholm 3361 715 349-7286 <br /> Plumbei s Address(Street,City,State,Zip Code): 11-1 <br /> 24702 Lind Road P.O. Box 514 Siren, WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Pe itas(InclUdesSurc rGroundwater <br /> roun water a Issuing A en ig atur N S p ) <br /> Approved ❑ Owner Given Initial O <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: f / <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />