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SANITARY PERMIT APPLICATION <br /> �faL IR In accord with ILHR 83.05,Wis.Adm.Code <br /> COUNTY�• _ STATE SANITARY ERMIT#,.)'i <br /> –Attach complete plans( the county copy only)for the system,on paper not less than )-77-t t 7; :59OI <br /> 8'%x 11 Inches In size. Eleck If revisl0 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. - <br /> PROPERTY OWNER PROP 1R LOCATION <br /> Mcten and Linet Jensen J� '/4 JE'/a,S T N, R (o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> P.U. Box 625 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> GhanAbuxq, (UI 54840 715 463-5847 E 1/2 NW 1/4 SE 1/4 <br /> II. TYPE OF BUILDING: Check one) El state Owned VILLLAGE NEAREST ROAD <br /> Wood RiveA Month Road <br /> ❑ Public ®1 0 2 Fam. Dwelling-#of bedrooms 'JPARCEL <br /> Ill. BUILDING USE: (If building type is public,check all that apply) �-]_ �,5' 3— 03- / W <br /> 1 ❑ Apt/Condo 1 <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. ® 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 ❑ SeepageTrenc 22 ❑ In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYST M INFORMATION: <br /> 1.GALLONS PER DAY 2 ABSORP.AREA 3.ABSORP.AREA 4. 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 /> 450 375 376 1 .2 4 99.9 Feet Mound Feet <br /> VII. TANK CAPACITY Site <br /> Cin allona Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks at <br /> Septic Tank or Holding Tank qbaw <br /> Lift Pump Tank/Siphon 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 Signature:IN Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade RuAshofm �6 e 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.U. Box 514 SiAen, (OI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disipprcved Sanitary Permit Fee(Includes Groundwater Datessu lasui ent Signa r (No Stamps) <br /> Approved ❑ Owner G vet Initial Q'f I�-/,� Surcharge Fee) <br /> 00 <br /> v t r in i n —!� JV �.`J <br /> X. CONDITIONS OF APF ROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R. 1/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />