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x:96- SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STATE SANITARYERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than C�gO S� a�b Oy 1 <br /> 8'%x 11 inches in size. ❑ Check if revision to previous application <br /> -See reverse side for instructions for completing this application. STAT pPLAiN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. I'I "jo-?ci k <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Duane Hayes '/4 ''/4, S 12 T 37 , N, R 18 IFX(or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# - <br /> 738 S. Piety <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Ellswoth, W1 54011 715 273-3184cl. G.L. 1 <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE' NEAREST ROAD <br /> Lake rX TOWN OF: TrSdi; <br /> Public Access <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms PARCEL TAX NUMBER(S) <br /> Ill. 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. ® 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 /> 300 NA NA NA NA NA Feet Feet <br /> VII. TANK CAPA6lotalAof <br /> Site <br /> in alPrefab. Fiber- Exper. <br /> INFORMATION New Gllons nks Manufacturer's Name Concrete Con- Steel glass PlasticApp <br /> Tanks strutted <br /> Septic Tank or Holding Tank 2,0001 ,000 1 2 1 Skaw <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 Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Rufsholm 4' �� 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.O. Boa 514 Siren WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater [Date Issued Iseult A ants igna ( o Stam s) <br /> roved ❑ Owner Given Initial r�J� _arge Fee) _ 1 <br /> P Adverse Determination V v ��—q� <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 />