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/�, MEMMI SANITARY PERMIT APPLICATION COUNTY <br /> V D1LHR In accord with ILHR 83.05,Wis.Adm. Code BU:ZDT�3TT <br /> �v��„�y„� ST TESANITARY ER,M, IIIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8'%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE ITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FO VARIANCE ❑YES � NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> PnII❑ TVFEYTR N':V % 9111/4, S 10 T 9 , N, R a4 )W <br /> PROPERTY OWNER'S MAILING ADDRESS LOTNUMBER BLOCK NUMBER SUBDIVISIC NNAME <br /> STAB 3CUT ' BOX 4144B NA NA NA <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST OAD,LAKE OR LANDMARK <br /> POON�.R 7I 4801 VILLAGE : RUSK 0 IIf;'lY G <br /> TOWN Of <br /> If. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 10 OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4, if applicable) <br /> L] L <br /> 1. a. New b. x Replacement c. ❑ Replacement of d. ❑ Reconnection of e.❑ Repair of an <br /> System System Septic Tank Only an Existing System Existing System <br /> 2. ❑ A Sanitary Permit was previously issued. Permit# Date Issued <br /> 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. <br /> 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership AgreemE nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. ®Conventional b. ❑Alternative c. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. ® Seeii e Bed b. ❑Seepage Trench c. ❑ seepage Pit <br /> 2. PERCOLATION RATE 13. ABSORPTION AREA 14. ABSORPTION AREA T92.9 <br /> YSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet <br /> 3 2050 2052 Feet ® rivate El Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Ste I Fiber- Plastic Aper. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> T Tanks strutted <br /> Se licTankorHoldin Tank 2 2 '..- IFRI S X ❑ <br /> Litt Pum Tank/Si hon Chamber 15 156 1 '' 'I SE IS X L1 <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plan <br /> Plumber's Name(Print): Plumber's Signature:(No StampsMP/MPRSW No.: Bt siness Phone Number: <br /> ARLYN J. xPLbl 3360 715 635-7595 <br /> Plumber's Address(Street,City,State,Zip Code): I IName of Designer: <br /> P.O.BOX 71, SPOON ?R, 'iiI 54801 <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> S A'i;Ls' 3'31 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved S nitary Permit Fee Groundwater ate Issuin gents nature(No Stamps) <br /> Approved ❑ Owner Given Initial /4T Surcharge Fee <br /> Adverse Determination - ULJ lA1/�lJ <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumbe <br />