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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code co NTY 11 II <br /> STANj,,4gq yPERMIT IC1O <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than a\r <br /> 8%x 11 inches in size. ❑ Check 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. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Clark Jewell wE WL0%, S 33 T 39 N, R 17 XE (or)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 9651 County Road V I <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Webster. WT (715 _ pcl. NE NW <br /> El FIT7-If. TYPE OF BUILDING: (Check one) El State Owned ❑ VILLAGE NEAR ST ROAD <br /> Lincoln County Road D <br /> ElPublic 511 or 2 Fam. Dwelling—#of bedrooms 3— ARCELTAX NUPBET <br /> ) <br /> III. 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 ❑ Oth r: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. ❑ 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 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED AREA <br /> ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 450 643 648 .69 NA 93.4 Feet 95.8 Feet <br /> VII. TANK CAPACITY Site <br /> in all ns Total #Of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdinfl Tank <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached p lans. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Rufsholta �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 /> Disapproved Sanitary Permit Fee(Includes Groundwater ate IssuedIssuing t Si nat re(ryo St�a Ps) <br /> _% <br /> kpSurcharge Fee) <br /> pProved ❑ Owner Given Initial ci) <br /> Adverse Determination ` l <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SB66398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Ow er,Plumber <br />