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SANITARY PERMIT APPLICATION <br /> 7DILHR In accord with ILHR 83.05,Wis.Adm.Code COUNT <br /> • � STAT ANITARYRMIT#j45qS9 <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ❑( �70 <br /> 8%x 11 inches in size. Check If revisl 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 /> PROPERTY OWNER PROPERTYLOCATION <br /> Geon e Bnodmson g '/4 '/4,S 10 T38 , N, R 17 E(or&� <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 23950 To tandeh Road #2 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Sihen, W154872 715 349-7318 c2. SE 4 NUI i 4 <br /> 11. TYPE OF BUILDING: (Check one) I177 <br /> 1: NEAREST ROAD <br /> State Owned VILLAGE: Danie.Ls <br /> ❑ Public1(❑1 or 2 Fam.Dwelling-#of bedrooms 2 PAR WN 0;1 <br /> L TAX NUMBEK(b) <br /> 111. 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. 0 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 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 480 480 .63 4 95.5 Feet 98 Feet <br /> VII. TANK CAPACITY Site <br /> in allona Total #of Prefab. Fiber- Exper. <br /> INFORMATION New iatl Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App. <br /> Tanks Tanks structed <br /> Septic Tank or Holdino Tank 750 750 1 1 Skaw <br /> Litt 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 Signatur No Stam I MP/MPRSW No.: Business Phone Number: <br /> Wade Rub.6hotm ,�/,-j - 1 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.U. Box 514 Sinen, W1 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agen SI ature o S ) <br /> r� Suroharge Fee) <br /> Approved ❑ Owner Given Initial _ S.M <br /> Adverse Determination V <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-M8(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety B Buildings Division,Owner,Plumber <br />