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�ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couNTv <br /> �._ NN r <br /> STATE UNITARY PERMIT#hrvfa7 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than / `7,� ��//�/ <br /> 8'k x 11 inches in size. ❑ c k H rev+slo 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. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Ke ty Knutun '/4 ''/4,S 14 T39 , N, R 16 E (or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> W 8009 150th Ave. <br /> CITY,STATE ZIP CODEPHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Na eA City, WI 54014 715 792-2299 pct. G.L. 4, V. 388, P 209 <br /> CITY NEAREST ROAD <br /> 11. TYPE OF BUILDING: (Check one) State Owned VILLAGE Meenon East Bam Lake Road <br /> [] Public ❑x 1 or 2 Fam. Dwellingof bedroomsxN <br /> Ill. BUILDINGUSE: (If building type is public,check all that apply) 018-3314-03 200 <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 ❑ RestauranttBar/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 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 14. LOADINGRATE 15. PERC.RATE 16. SYSTEMELEV. 7. FINAL GRADE <br /> REQUIRED(aq.tt.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 480 480 .63 4 97.5 Feet 99.8 Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank 800 --- 800 1 Skaw <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. 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 Rujzhotm � 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.U. Box 514 SiAen, WI 54872 <br /> IX. OUNTY/DEPARTMENT USE ONLY <br /> Disapproved I Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Ag t si lure lamps) <br /> Approved ❑ Owner Given Initial Surcharge Fee) C� '0 1 <br /> A v rseD rmin i nI� � ID_o4:3 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />