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SANITARY PERMIT APPLICATION <br /> 0ILHR In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STATE SANITARY PERMIT# IgSglq <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than El <br /> ��\ "I I <br /> 8'%x11inches insize. Cecklfre elontopreviousapplication <br /> —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. SG3- 9,cA(o5_ <br /> PROPERTY OWNER PROPERTY LOCATION <br /> TeAAy Betizte Y4 Y4,S 6 T39 , N, R 16 E (or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 2172 Goose Lake Road <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> New Richmond, WI 54011 715 248-3952 ct <br /> It. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ❑ State Owned VILLAGE: Meenon Jam2�son Road <br /> ❑ Public X❑1 or 2 Fam.Dwellings of bedrooms WOWu ) <br /> 111. BUILDING USE: (If building type is public,check all that apply) 19— 330(o—. O'_9CD <br /> 1 ElApt/Condo �� I�JJ <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. X❑ 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 /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAI 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 450 N/A N/A N/A N/A I N/A Feet N/A Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New isti Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank 2 00 2,000 <br /> Lift Pump Tank/Siphon Chamber <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:IN Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Ru bhotm c-7, 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Cade): <br /> 24702 Lind Road P.U. Box 514 SiAen, WI 54872 <br /> I COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater ate Issued Issuing A e igna a(No Ste <br /> pproved El owner Given Initial surcharge Fee) <br /> Adverse Det rmin i n ( b —_13 YTS <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 8 Buildings Division,Owner,Plumber <br />