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M"" SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis. Adm. Code Co NTY <br /> STA SAN ITA fZY PERMIT <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than J\ `7\ <br /> 8'/2 x 11 inches in size. 13 <br /> Check if revision to previous application <br /> —See reverse side for instructions for completing this application. STA rE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Bryan B"orklund NE '/4 NW '/4, S 28 T 39 , N, R 17 (or)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOC # <br /> P.O. Box 658 <br /> CITY,STATE ZIP CODE 4D 1 PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Grantsburiz. WI 54R (715 )61819-2 IjL <br /> II. TYPE OF BUILDING: Check one CITY NEAR ST ROAD <br /> ( ) El Owned 0 VILLAGE <br /> ❑ Public 4 Ice Hous <br /> ®1 or 2 Fam. Dwellings of bedrooms— PARC LTAx NUMB ( ) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) 0 <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Out oor 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 DAI 2.ABSORP.AREA 3.ABSORP.AREA i 4. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 600 857 864 .6NA 41A A Feet Q7 Feet <br /> VII. TANK CAPACITY Site <br /> in alit Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New xis"r. Gallons of Concrete glass App. <br /> Tanks Tanks Site <br /> Septic Tank or Holding Tank 1250 1 Skaw <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 Stamps) MP/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 WT �AR72 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Pe mit Fee(Includes Groundwater Date IssuedIssuing A n Sigat r ( S ps) <br /> 14Approvetl ❑ Owner Given Initialrge Fee) �—C <br /> Adverse Determination t � <br /> I�O <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SB66398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Own r,Plumber <br />