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tatat. SANITARY PERMIT APPLICATION COUNTY(M4NE—h.. <br /> �I IRM In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITARY PERMIT#� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than Cl0C)6 j) 3i�q_rn <br /> 8'f.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. <br /> PROPERTYOWNER PROPERTY LOCATION <br /> Bob Carlson NW '/a IOW ''/a, S 22 T 40 , N, R 16 rC(or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 27866 Robbie Road <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Webster, WI 54893 715 866-8293 <br /> II. TYPE OF BUILDING: (Check one) El CITY NEAREST ROAD <br /> State Owned 0 VILLAGE <br /> ��11 Count Road C <br /> ❑ Public L31 or 2 Fam. Dwelling #of bedrooms PAR LTAX NUMBER( ) <br /> 111. BUILDING USE: (It building type is public,check all that apply) �.� —y _0\—q C0 <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 DAV 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 /> 643 648 .69 WA 95 Feet 1 97.4 Feet <br /> VII. TANK CAPACITY Site <br /> in allons I Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Se tic Tank or Holding Tank 11 ,0001 1 1 Wieser <br /> Lift Pum Tank/Si hon 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 StampMP/ <br /> s) MPRSW No.: 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 /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ DisapprovedSanitary Permit Fee (includes Groundwater ate IssuedIssuin nt Si natur No Stamp ) <br /> Approved ❑ Owner Given Initial Surr�har0e Fee) /5, <br /> Adverse Determin tion <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />