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6 117Yc <br /> Safety and Buildings Division <br /> ` �nSANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> isciadsin In accord with(LHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8112 x 11 inches in size. Burnett (o�a�b4o <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> X30_3 <br /> Personal information you provide may be used for secondary purposes ❑Check if revision t(previous application <br /> [Privacy Law,s. 15.04(1)(m)1. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Property Location <br /> Rick Larson SE 1/4 SE 1/4,S 6 T 8p ,N, RgU (or)W <br /> Pro�0k ert Owner's Mailing Address Lot Number Block Number <br /> County Road % <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Webster, WI 1 54893 ( 715)866-7178 <br /> 11. TYPE BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road <br /> Public 1 or 2 FamilyDwellingNo.of bedrooms 3 °Town of Dewey Oak Road <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel Tax Numbers) <br /> 008-2106-04 500 <br /> 1 ❑ Apartment/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 box on line A. Check box on line B,if applicable) <br /> A) 1. ® New 2_ ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> _ System _ _ SystemTankOnly-__---_-___ Existing System _ Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 a Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12❑Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 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 /> 450 Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 61 648 96 Feet 98.4 Feet <br /> TANK Capact <br /> VII. <br /> INFORMATION in allons Total #of Manufacturer's Name Prefab. Site Con- steel Fiber- Plastic Exper <br /> New Existin fConcrete Gallons Tanks Cte strutted glass App. . <br /> Tank T nks <br /> Septic Tank or Holding Tank 1,000 — 1,000 1 Skaw ® ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I 1 ❑ ❑ ❑ ❑ ❑ ❑ <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 Signature:(No Stamps) MP/MPRSW No.: <br /> Business Phone Number: <br /> Wade Rufsholm 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 /> 11K. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee pndudesGroundwater Fate Issued Issuing ent Signature,(No Stamps) <br /> roved Surcharge Fee) <br /> pp ❑Owner Given Initial 14 I y � Qo _aa , Y)�`.� <br /> Adverse Determination I <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11197) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />