Laserfiche WebLink
DILH '2 SANITARY PERMIT APPLICATION <br /> _ In accord with ILHR 83.05,Wis.Adm.Code couNTv <br /> - s r <br /> ���• � STATE SANITARY RM IT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than / ,_-�, <br /> 834 x 11 inches in size. ❑ Check if revla d o 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 /> Brian and Mary Peterson NW t% NE t%,S 13 T 38 , N, R 17 E (or)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 23975 Peterson Road <br /> CITY,STATE ZIP CODE PHONE NUMBER5325 SUBDIVISION NAME OR CSM NUMBER <br /> Siren WI 1 54872 715 349-7286 <br /> I1. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE NEAREST ROAD <br /> Daniels Peterson Road <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms 2 LAX NUM <br /> III. BUILDING USE: (If building type is public,check all that apply) Ni _ a q <br /> 1 ❑ Apt/Condo <br /> 2 El Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 El 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 in line A. Check line B if applicable) <br /> A) 1. ❑ New 2. 0 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 71 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PER <br /> C.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 480 600 .5 5 95 Feet 97.1 Feet <br /> VII. TANK CAPACITY Site <br /> in allons 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 Holdina Tank 750 750 1 'IMC 171 F <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 plans. <br /> Plumber's Name(Print): Plumber's Signature:( o Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Rufsholm �J 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.O. Box 514 Siren WT 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e Issued Issuing Agent Si ature(No Stam s) <br /> Approved E] Owner Given Initial Surcharge Fee) <br /> Adverse De r in i n �C�l �� ��-7-'� <br /> X. CONDITIONS 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 />