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SANITARY PERMIT APPLICATION COUNTY r <br /> 70ILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> ��•�� STATESAN ITARY P�ERMIT#1$6�� <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ❑ ` 1 X501 1 <br /> 8'%x 11 inches In size. Check if revislo 4o 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 /> Wi"ton 6 Peggy RodackeA '/4 '/4, S 33T 11 , N, R 16 E(or49 <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 850 Knowtu Ave. N. <br /> CITY,STATEZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> New Richmond, WI 54017 pct. G.L. 5 <br /> If. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ❑State Owned VILLAGE: � Round Lake Road <br /> ❑ Public Ell or 2 Fam. Dwelling–#of bedrooms 2 PARCELTAX NUMBERS) <br /> III. BUILDING USE: (If building type is public,check all that apply) — oi��F_5DD <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 E1Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranVBar/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. ❑ 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 PE7DAY 2.ABSORP.AREA 3.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 /> 30480 480 .63 2 98.9 Feet 100.9 Feet <br /> VII. TANK CAPACITY Site <br /> in al Ions Total #of Prefab. Fiber- Exper. <br /> INFORMATION New is8n Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdino Tank <br /> Lift Pum Tank/Siphon Chamber 600 600 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signatu�S ) MP/MPRSW No.: Business Phone Number: <br /> Wade Ru.6�shotm �,� 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Codej: <br /> 24702 Lind Road P.U. Box 514 S«en, WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E] Disapproved Sanitary Permit Fee(Includes Groundwater ate Issued Issuing Ageign ps) <br /> Surcharge Fee) _ <br /> Approved ❑ Owner a Den Initial X11 <br /> Averse Determin tion ..7 <br /> X. 6ONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />