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SANITARY PERMIT APPLICATION <br /> �ILHR In accord with ILHR 83.05,Wis.Adm.Code co NTY <br /> ���• � STATE SANITARY PERMIT# \r <br /> -Attach complete plans(tot is county copy only)for the system,on paper not less than C l?b?1) <br /> 8%x 11 inches in size. ❑ Check if revision to previous application <br /> -See reverse side for instru tions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> JeAAy MoaeA '/4 %,S 29 T 40, N, R 15 E (or) W <br /> PROPERTY OWNER'S MAILING AC DRESS LOT# 5 BLOCK Ill <br /> 26712 FAeepoAt Ave. <br /> CITY,PT mEng, MN IP ODE2 PHONENUMBER SUBDIVISION NAME OR CSM NUMBER <br /> SS((//yy 612 462-2829 CSM Vot. 8. Pg. 3 <br /> II. TYPE OF BUILDING: (Ch k one) State Owned CITY NEAREST ROAD <br /> VILLAGE Jackson MoaeA Road <br /> ❑ Public x❑1 ort am. Dwelling-#of bedrooms UM <br /> Ill. BUILDING USE: (If building type is public,check all that apply) (,�� - �, �- U <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 ❑ Ottice/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. U1 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: (Ch k 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 SYSTEMINFORMATION: <br /> 1.GALLONS PER 1 2.AE SORP.AREA 3.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REO IRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 480 480 .63 4 95.5 Feet 97.8 Feet <br /> VICAPACITY <br /> I. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New Istin Gallons Tanks Manufacturer's Name ConcreteCon- Steel glass Plastic App <br /> anks Tanks strutted <br /> Septic Tank orHoldin Tank 50 --- 750 1 WCP <br /> Lift Pump Tank/Siphon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume rei iponsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:IN mpa) MP/MPRSW No.: Business Phone Number: <br /> Wade Rubahokm � � 3361 715 349-7286 <br /> Plumber's Address(Street,City,St ate,Zip Code): <br /> 24702 Lind Road P.o. Box 514 S Aen, WI 54872 <br /> IX. COUNTYIDEPARTMEN7 USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater as as Issuing gent Si ature( Stamps) <br /> O � Cy�pproved ❑ Syr <br /> cherge Fee) <br /> Adverse Determination <br /> 0 94 <br /> X. CONDITIONS OF APPRO VALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/ DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />