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DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis. Adm.Code <br /> STATE$AN ITAERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than C l� / I <br /> 8%x 11 Inches In size. Check if rewsi n o previous application <br /> -.See reverse side for Instructions for completing this application. STATE PLAN I.D.N MBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTYL TION <br /> Stephen Brown E'/s `�' Ya,S 20 T40 , N, R 17 E (or)IR <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 28271 South Riven Road <br /> CITY,STATEZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Danbury, W1 54830 715 656-3168 pct. SE 1/4 NW 1/4 <br /> II. TYPE OF BUILDING: (Check one) 1:1CITY NEAREST ROAD <br /> State Owned CITY ; Union South Riven Road <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms 1 PARUFL I AX NUM R( ) <br /> III. BUILDING USE: (If building type is public,check all that <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 ElRestauranvBar/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 M 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 /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PE7DAY 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 /> 150240 480 .31 3 94.9 Feet 97.3 Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding <br /> Tank 750 --- 7 T <br /> MC H H F1 <br /> Lift Pum 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 Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> (Dade Rubsho m 3361 715 349-7286 <br /> Plumber's Address(Street,City,Stale,Zip Code): <br /> 24702 Lind Road P.U. Box 514 Si)ten, I 54872 <br /> X. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e ssue Issuing Age natur (No Stamps) <br /> Approved Surcharge Fee) Y <br /> ❑ Owner Given Initial IOJ• �� ,n a-5� ` <br /> Adverse Determination L <br /> X. CONDITIONS OF A <br /> PPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/96) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />