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t"cMLP, <br /> Safety and Buildings Division <br /> E <br /> EbbBureau of Building Water Systems <br /> r. SANITARY PERMIT APPLICATION201 E Washington Ave. <br /> In accord with ILHR 83 05,Wis.Adm.Code P.O.Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanity )ISIO <br /> rmit Number aGSLI g <br /> I n YtYC�� <br /> The information you provide may be used by other government agency programs ❑ k if re to previous application <br /> [Privacy Law,s. 15.04(1)(m)I. <br /> State Plan I.D. umber <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> Sim Olson NW 1/4 Nig 1/4,S is T39 ,N, R16 (or)W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Box 24 <br /> City,State Zip CodePhone Number Subdivision Name or CSM Number <br /> Webster, WI 54893 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms I F Town of Neenon County Road x <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Numbers) <br /> 1 ❑ Apartment/Condo A--3 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Resta rant/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 box on line A. Check box on line B, if applicable) <br /> A) 1. jL] New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ------System System TankOnly Existing System__________ExistingSystem <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number 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 Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1. Gallons Per Day 2. Absorp.Area3. 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 /> 450 643 900 <br /> Feet Feet <br /> Capact VII. TANK in allons Total #of Prefab site Fiber- Exper <br /> INFORMATION g Gallons Tanks Manufacturer's Name Concrete C n- steel glass Plastic App <br /> New Existin sir cted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 1,000 -- 1,000 1 S1eav ® 1:1 ❑ ❑ ❑ ❑ <br /> I lft Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown n the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature:(No mps) MP/MPRSW No.. Business Phone Number: <br /> Wade Rufsholm � 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 /> ❑Disapproved Sanitary Permit Fee (mdudes Groundwater Date Issued Issul gAg nt <br /> S (N'o Stamps) <br /> Approved ❑Ownes al � I� �su"har9eFee) <br /> Adverse Determination <br /> � <br /> X. ONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> 5X11098(11.CY94) DISTRIBUTION- Oo,.nai to Cnu., ,One<n PY To: SA.1,B B...I&n,,Oivulon,owner.Plum r <br />