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DILI-IR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNn <br /> STATE ITARYRMIT#1�5/I. <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than l 7 7 <br /> 814 x 11 inches in size. IICheck if revision 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 /> PROPERTY OWNERS PROPERTY LOCATION <br /> ChAi,s Witzany %4 '/4, S 25 T 38 , N, R 18 E(orb <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> P.U. Box 39 <br /> CIN,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> GAawt,5bu)t9, WI 54840 715 )689-2720 c2. G.L. 6 <br /> III. TYPE OF BUILDING: (Check one) LJ State OwnedCITY Ra <br /> VILLAGE Waad ven NEAREST ROAD <br /> El Public © s OF� Llttte Wood Lake DAive <br /> 1 or 2 Fam. Dwellingof bedrooms 3 L IAX R( ) 2 <br /> III. BUILDING USE: (If building type is public,check all that apply) ( — AS as— of—OoD <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 DAI 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 ------- ------ -------- ------ ----- ----- <br /> Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New istin Gallons Tanks ncret strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank000 -_ <br /> 2,0001 1 1 Skaw X <br /> Lift Pum Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,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 Ruphokm 3361 It 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): le <br /> 24702 Lind Road P.U. Box 514 S(Aen, WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e ssu Issuing Agent natur o s) <br /> proved ❑ Owner Given Initial �surrc-hharge Feel / (}-� <br /> Adverse Dt rmination s «S� W �-7--I� <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />