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SANITARY PERMIT APPLICATION - <br /> 70--LCOUNTYHR In accord with ILHR 83.05,Wis.Adm.Code $URNETT <br /> �. <br /> STATE SANITARYY��ERMIT#LSM <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ js6Z18) <br /> 8'k X 11 inches In size. Check If revisi6n 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 /> DALE PETERSON '/4SW '/4,S 25 T 40, N, R 14'114* W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# nn BLOCK# <br /> 1150 WEST PONNT RD HCR59 Gov'ib.Lar3 NSA <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> SPOONER,wi 54801 N 'A <br /> It. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned VILLAGE: SCOTT WEST POINT <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms 2 R LTAX NUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) I- <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. TYIIPPE�E OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. 5iNew 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 5. PER' RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 410 420 .71 3 93.7 Feet 95.2 Feet <br /> VII. TANK CAPACITYin allons Total Site <br /> INFORMATION Tanks <br /> Prefab. Fiber- Exper. <br /> New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdino Tank OOL-- 1 8001 1 1 SKAWY <br /> Litt Pum Tank/Si hon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibilityor Installation of the Ofte sewage system shown on the attached plans. <br /> Plumber's Name(Print): I m SignatF(N mpa) MP/MPRSW No.: Business Phone Number: <br /> MEL J. PERGUSON 3393 71 -635-7482 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> HCR59 BOX478d SPOONER, WI 48 <br /> IX. POUNTYIDEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e esus issuing Appe Signat re(No!Btamps) <br /> Approved ❑ Owner Given Initial /V5. _ $eroharse Fee) �f'� � <br /> Adverse Determinationi <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-M(formerly Pib-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />