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DILHR SANITARY PERMIT APPLICATION COUNTY r <br /> __ In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITARY RMIT#a���/ _ <br /> Y� <br /> -Attach complete plans(tot a county copy only)for the system,on paper not less than )l5`(� <br /> 8%x 11 inches in size. Elcn k i revlsi to previous application <br /> —See reverse side for instrU Ions for Completing this application. STATE PLAN I .NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTYOWNER PROPERTY LOCATION <br /> Ra eA Wood AP4 '/4 _e Lr- S 35 T 38 , N, R 18 X(or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 22589 L<tt2e Wood Lake Road <br /> CITY,STATE- <br /> IP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> GAantstI WI 54840 715 689-2327 N 1/2 N 1/2 SE 114 <br /> NEAREST ROAD <br /> IL TYPE OF BUILDING: (Check one) El State Owned VILLLLAGE:T11WN @F. wood RLveh Little Wood Lake Road <br /> ❑ Public ®1 or 2 Fam. Dwelling#of bedrooms 3 PARCEL TAX NUMBEK4 <br /> III. BUILDING USE: (If building type is public,check all that apply) <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. X Replacement 3. ❑ Replacement of 4.❑ Reconnection m Existing System <br /> 5.❑ Repair of an <br /> System System Tank Only Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit# — Date Issued <br /> V. TYPE OF SYSTEM: (C eck 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 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL ELEVATION GRADE <br /> RE UIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) <br /> 450 NA NA NA NA NA Feet NA Feet <br /> VII. TANK in allons Total #of CAPACITY Site Fiber- Exper. <br /> Prefab. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> strutted <br /> Tanks ITanks <br /> se tic Tank or Holding Tank 2 00 --- 2,000 1 skate <br /> Lift Pum Tank/Si hon Chambe <br /> Vlll. 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.: Business Phone Number: <br /> Wade Rubahotm 3361 715 349-7286 <br /> Grc- <br /> Plumber's Address(Street,City State,Zip Coder <br /> 24702 Lind Road P.U. Bax 514 Si)ten, WI 54872 <br /> IX COUNTYIDEPARTME T USE ONLY Iss n ant S' n ere(No Stamps) <br /> �Ad <br /> d Sanitary Permit Fee(Includes Groundwater a e eau 9 9 <br /> C Surcharge Fee) / <br /> Approveden Initial I C�a I"CD Ll-�I -� LGGr <br /> oterminatiQn J <br /> X. CONDITIONS OF APPI IOVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.1 /88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />