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SANITARY PERMIT APPLICATION <br /> .�����■ COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code �r� <br /> STATE SANITAY PERMIT#l,, <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ��� �0 I <br /> 8'%x 11 inches in size. ❑ Check if revision to 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. S9 -Ao <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Charlie Moen A,/E /a, S 12 T 39 N, R 17 L'(or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> Boa 237 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Webster, WI 54893 cl. NE <br /> 11. TYPE OF BUILDING: (Check one) 1:1 CITY NEAREST ROAD <br /> I�a State Owned 0 VILLAGE Lincoln Helsene Road <br /> ❑ Public L91or2Fam. Dwelling—#ofbedrooms 3 PAR ELTAxNUMBEER(` ,) <br /> III. BUILDING USE: (If building type is public,check all that apply) 0,6 >—t I —O ?' /0O <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 ❑ 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 PER DAY 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 /> 450 585 585 .77 4 96.7 Feet 1 99.2 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdinut Tank 000 -- i 1,0001 1 1 WCP 11 1 Ll <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:(No mps) MP/MPRSW No.: Business Phone Number: <br /> Wade Rufsbolm C-�C tu-� 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Cod4y.1 <br /> 24702 Lind Road P.O. Box 514 Siren, W1 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater [Date issuedIssuin A ent Signat re(Nos mps) <br /> Approved ❑ Owner Given Initial /t 0� Surcharge Fee) I�I� <br /> Adverse Determination -43 Sv <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety B Buildings Division,Owner,Plumber <br />