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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> !�M STATESANITARY RMIT#II Z53q <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8'%x 11 inches in size. ❑ C k if evlslo o 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 /> Ben C. Blair 1/4 '/4, S13 T 40 , N, R 17 E(or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 28547 Pa1mberg Road parcel in Governmnt Lbt 3 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 54830 715 866-8562 <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE Union NEAREST ROAD <br /> Palmber Road <br /> ❑ Public ®1 or 2 Fam. Dwellings of bedrooms AX NUM <br /> III. BUILDING USE: (If building type is public,check all that apply) 036-4413-02 800 <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 ❑x Seepage Bed 21 ❑ Mound 30 ❑ SpecityType 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 PEF7 2.ABSORP.AREA 13,ABSORP.AREA 14. 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 /> 300 480 480 .63 2 96.4 Feet 98.9 Feet <br /> VII. TANK CAPACITY oncretSite <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Prefab. Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank7,0 <br /> 1 <br /> Lift Pum Tank/Siphon Chamber 1TMC <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: Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Rufsholm I 1 1 3361 (715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.O. Box 514 Siren WI 54872 <br /> IX./COUNTY/DEPARTMENT USE ONLY <br /> Disapproved I Sanitary Permit Fee(Includes Groundwater Date esus Issuing A nt Si at re o Stamps) <br /> XApproved / . Surcharge Fee) fj yOwner Given Initial ` �-j1 GL <br /> Adv Determination CCU <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 />