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SANITARY PERMIT APPLICATION coup+TY; <br /> v <br /> In accord with ILHR 83.05,Wis.Adm.Coded <br /> STA SANITARY ERMIT# �� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ 100 W_?� t��' I I <br /> 8'h x 11 Inches in size. heck if revision to previous application <br /> —See reverse side for Instructions for completing this application. STA E PLAN I.D.NUMBER_ <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. J c�0 -31' <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Dan Michaels '/4 /4, S 21 T 37 , N, 18 (or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOC # <br /> 20920 Lakewood Drive 1 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Grantsburg, WI 154840 715 327-4510 CSM Vol. 3 P . 190 <br /> CITY NEAREST ROAD <br /> it. TYPE OF BUILDING: (Check one) ❑ State Owned 0 VILLAGE Lake Lakewood Drive <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms PNA RELTAxNUMB ( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) ISC) <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 ❑ Ser ice 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 Bit applicable) <br /> A) 1. Ll New 2. ® Replacement 3. El Replacement of 4. ❑ Reconnection of 5.El 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 j2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. fIERCi RAE <br /> E 6 SYSTEM ELEV. 17. FINALELEVGRADE A E <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) <br /> 300 NA NA NA NA NA Feet NA Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> - <br /> R <br /> Tanks Tanks <br /> Septic Tank or Holdin Tank 2.00 -- 2,000 1 Skaw <br /> Lift PumD Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached Aans. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Rufsholm 1 3361 1 _ <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.O. Box 514 Siren WI 54872 <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> Disapproved Sam ryP rmit Fee(Includes Groundwater ate IssuedIssuin A enh6igna re N mps) <br /> rrte�^^ ❑ P SurCCcctthharge Fee) 1 <br /> IRIApproved ❑ Owner Given Initial �J�1 <br /> '"'""tom Adverse Determination V <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,0 1v <br /> ner,Plumber <br />