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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STAT SANITA Y PERMIT#- <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ! c~'�� = j <br /> 8'%x 11 inches in size. ❑ Check it revision 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 /> Mike Waltzing HW '/s bZ %, S 32 T 40 , N, R 16 lE(or)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> P.O. Box 497 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME,9R CSM NUMBER <br /> Webster, WI 54893 715 66-4605 �1 -SA � <br /> II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD <br /> % ) State Owned 2 TOWN HFVILLAGE Oakland St. Hwy. 35 <br /> ❑ Public ❑1 or 2 Fam. Dwelling,#of bedrooms— PARCEL TAX NUMBER(S)\\ <br /> Ill. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo <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. R 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 DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.I (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 500 714 864 .58 NA 95.4 Feet 97.9 Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New istin Gallons Tanks oncret structed glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 12501 -- 1 1250 1 Skaw L7x F-1 F1 <br /> Lift Pump Tank/Siphon Chamber <br /> Vlll. 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/:(No Stamps) MP/MPRSW No.: __] Business Phone Number: <br /> Wade Rufsholm �✓Ckcf�/(�i' ��-- 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 /> �-//yy�� <br /> 0 Disapproved Sanitary Permit Fee(includes Groundwater ate IssuedIssuing en Sig atur ( S psI <br /> [Xpproved ❑ Owner Given Initial r r5nprge Feel �.�, _ tIt <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />