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WTI- F,(V 1J ZSR 1 CaYYI� <br /> SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code co NTY <br /> STA E SANITkRY PER I # <br /> -Attach complete plans(to the county copy only)for the system,on paper not less thanlf\ <br /> 8'/z x 11 inches in Size. heck if revision to previous application <br /> -See reverse side for Instructions for completing this application. STA E PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. U <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Mike and Donna Chell %,X 14 %, S 21 T 38 , N, R 18 Y6 (or)W <br /> PROPERTY OWNER'S MAILING ADDRESS L BLOCK# <br /> 23475 County Road Y <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Gratnsburg, WI 5484 715 689-235 <br /> If. TYPE OF BUILDING: (Check one) ❑ State Owned H1 VI AGE NEAR u ROAD <br /> . Grantsburg C unty Road Y <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms 3 RCELTAX NUMBER( ) <br /> III. BUILDINGUSE: (If building type is public,check all that apply) �`j�r�-�Sa , ,- -�,© <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Out oor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Re auranUBar/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 H 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 PER7DAY2.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.tt.) (Min./inch) ELEVATION <br /> 450643 563 .7 NA 96.5 Feet 99 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or HoldinTank ' ' <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 p lans. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade RnfE 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 Sanitary P Fee(Includes Groundwater I Dateissuedldissuing g nt Signa u o t mps) <br /> Approved ❑ Owner Given Initial d-F ' urch+{g',Fae) C, <br /> Adverse Determination <br /> ."h`.ti KJ �-(r <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 6 Buildings Division,Ow at,Plumber <br />