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SANITARY PERMIT APPLICATION <br /> v 0LAA COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code � <br /> STATE SANITA YPERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 61 -`�Id040 <br /> 8'%x 11 Inches In size. ❑ Check If revs ion to previous application <br /> -See reverse side for Instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Randy Fosberg 1V(�'/a$ '/a, S 23 T 38, N, R 17 g(or)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 8825 Fosberg Road <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Siren, WI 54872 715 349-2286 d NE SW <br /> If. TYPE OF BUILDING: (Check one) CIN NEAREST ROAD <br /> State Owned 2 O VILLAGE: Daniels Fosberg Road <br /> El Public ®1 or 2 Fam. Dwelling-#of bedrooms— PA LTAX NUMBER( ) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) 066_ -oa-ado <br /> 1 ❑ ApVCondo <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. TYIIPPEII OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. L%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 ® 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 /> V1. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 12.ABSORR AREA 13.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 300 REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 429 480 .63 KA 93.9 Feet 96.4 Feet <br /> VII. TANK CAPACITY Site <br /> in all ns Total #of Prefab. Fiber- Last, Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass cApp <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank <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 /> Business Phone Number: <br /> Plumber's Name(Print): Plumber's Signa[ur , No Stamps MP/MPRSW No.: <br /> Wade Rufsholm rte/ / 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.O. Boa 514 Siren, WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater r0Te issued Issum and Signa re(No S mps) <br /> Surcharge Fee) L F-1� �� <br /> pproved F-1 Owner Given Initial 'V �5 �y- <br /> Adverse Determinali n „f•� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety B Buildings Division,Owner,Plumber <br />