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Cil (/0YI l-f. <br /> DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STATESANITARY fill# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ ( <br /> 8'h x 11 inches in size. c eck If reviaiyr(to previous application <br /> —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. V t. Cu I <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Steve Sta teton '/a '/<, S 12 T 40 , N, R 14 E (Or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> W 7312 S tvezten 111 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Hotmen, WI 54636 608 526-4599 CSM Vat. 13 P 2 <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ❑ State Owned VILLAGE Scott Cahhon Road <br /> ❑ Public Z1 or 2 Fam. Dwelling,#of bedrooms A TAx M ( ) <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. 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 El Mound 30 ❑ Specify Type 41 El 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 12.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERCRATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.If (Min./inch) ELEVATION <br /> 300 750 756 .4 5 96.2 Feet 98.7 Feet <br /> VII. TANK CAPACITY Site <br /> in at ons Totf <br /> al #of Prefab. Fiber- p . <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name n <br /> Concrete Co - Steel glass ApppPlastic A <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 100 --- 1 000 Skauw <br /> Lift Pum Tank/Si hon Chamber 600 -- 600 <br /> Vlll. RESPONSIBILITY STATEMENT <br /> 1,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 Rubehotm 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.U. Box 514 Sihen, WI 54872 <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Grounawater as ssue Issuing A nt S lure tamps) <br /> �Srur�ch�rge Feel <br /> pproved El Owner Given Initial �� �os �/ <br /> AdverseDeterminationIF <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBO-8399(formerly Plb-67)(R.11/98) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />