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DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code �NE(^ — <br /> STATE SANITARY MIT#�o�73►q <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ ��3 <br /> 8%x 11 inches in size. c irrevso 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 /> RobeAt Me eA 8 LavL LoAhOn '/4 '/4,S 13 T 40 , N, R 15 E(or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 4721 ShaAon Lane 3 <br /> CITY,STATE IF,CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER /'" _ <br /> White Bewc Lake, M 55110 612 26-4318 CSM Vat. 10, P 35 1Ijl/' � . LGJ <br /> It. TYPE OF BUILDING: (Check one) El CITY NEAREST ROAD <br /> InSI ❑State Owned VILLAGE lack.aan Rigby Road <br /> ❑ Public 121 or 2 Fam. Dwelling—#of bedrooms <br /> III. BUILDING USE: (if building type is public,check all that apply) 012-4213-06 420 <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. ❑ 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 El Mound 30 EJ SpecityType 41 El 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 DAY 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.h.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 480 480 .63 3 95.5 Feet 97.8 Feet <br /> VII. TANK CAPACITY Site <br /> in aIC' Total #of Prefab. Fiber- Exper. <br /> INFORMATION New iss Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank 800 1 --- 1 800 1 1 1 Straw <br /> Lift Pump Tank/Siphon Chamber <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:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Rub.aho m I e"t /, 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.U. Box 514 SiAen, WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E] Disapproved Sanitary Permit use(Includes Groundwater Date Issued <br /> Issuing Age ign r mps) <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial .� <br /> Adverse Determiilion <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />