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DItHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couNrr 75RIy1 11 �Af nI <br /> �V V' � VVVpp^n/^ <br /> STATES NITARY ERMIT#/d 800 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than Ab7 <br /> 8'fi X 11 inches In size. ❑ Check if revis n to previous application <br /> -.See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. oS –o2OO�SU <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Dave AndeAson '/. ''/s,S 31 T 40 , N, R 16 E(or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 1670 Hwy. 48 1A <br /> CITY,STATE ZIPCODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> FnedeAic, (UI 54837 715 327-8222 CSM Vol. 1 . 162 1!1 OV Lc)- <br /> (:- <br /> Cl <br /> TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned VILLAGE: pgand Jamieon Road <br /> ❑ Public ©1 or 2 Fam. Dwelling,#of bedrooms 2 L Ax Nu ( ) 7 <br /> III. BUILDING USE: (If building type is public,check all that apply) z-- <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 /> V1. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER 61 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 ----- -------- -------- ------ <br /> --------Feet ----- Feet <br /> VII. TANK CAPACITY Site <br /> in allona Total #of Prefab. Fiber- Exper. <br /> INFORMATION New isbn Gallons of Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tankor Holding Tank <br /> Litt Pump Tank/Siphon Chamber Ll <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:(N mps) MP/MPRSW No.: Business Phone Number: <br /> Wade Rubeho2m o 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.o. Box 514 Si)Len. W1 54879 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Income oundwate Fate IssuedIssu' g gent Sig t e(No Stamps) <br /> �Approved ❑ Owner Given Initial �1" I�S. ZD ge Fee) 3 <br /> Adverse Determination _$ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Pb-67)(R.11/83) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />