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DILHR SANITARY PERMIT APPLICATION r <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY-& <br /> mmmmms STATE;SANITA Y PERMIT#,-G P63 <br /> _CJ3 <br /> -Attach complete plans(t( the county copy only)for the system,on paper not less than <br /> 8'h x 11 inches in size. ❑ Check If rev ion to previous application <br /> —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMA ION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Dave Crtain '/a ''/a, S 7 T 40 , N, R 16 19(o )W <br /> PROPERTY OWNER'S MAILING kDDRESS LOT# BLOCK# <br /> 584 Lundy Lane 26 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Hudson, WI 54016 Riven Oahe <br /> II. TYPE OF BUILDING: (Check One) ❑ State Owned '0 VILLAGE NEAREST ROAD <br /> Uah2and West yekkow Riven Road <br /> r7!r TOWN OF: <br /> ❑ Public ®1 or 2 Fam.Dwelling-#of bedrooms A L ( <br /> 111. BUILDING USE: (If bui ding type is public,check all that apply) c;>Z—"I <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 E-1 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 Perrr it was previously issued. Permit# — Date Issued <br /> V. TYPE OF SYSTEM: (C heck only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 ® 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 PER DAY 12. kBSORP.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 /> 450 720 720 .63 3 95.9 Feet 98.5 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New is8n Gallons Tanks Manufacturer's Name ConcreteCon- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 1 ,01 - 1 ,000 1 WCP X <br /> Lift Pump Tank/Siphon Chambe <br /> VIII. RESPONSIBILITY S7ATEMENT <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 Ru6zhotm G�r�rCc— 3361 715 349-7286 <br /> Plumber's Address(Street,City State,Zip Code): <br /> 24702 Lind Road P.U. Box 514 S Aen, WI 54872 <br /> IX. COUNTYIDEPARTME T USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes <br /> Surcharge <br /> water Date IssuedIss g an t Sig et re( Stemps) <br /> ergsa Feel <br /> eeFee) <br /> Approved ❑ Owner Given initial <br /> A v termin tion <br /> X. CONDITIONS OF APPROVAL/REASONS;FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.1 /88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />