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DILHR SANITARY PERMIT APPLICATION COUNTY E <br /> In accord with ILHR 83.05,Wis.Adm. Code <br /> STATE ANITAR ���ERMIT#I�g <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �bs$r�1 <br /> 8'fs x 11 inches in size. ❑ Check if revisio to previous application <br /> -See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> John Vol ren 1/4 '/4,S 13 T 41 , N, R 16 E(o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> Box 188 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Balsam Lake, WI 54810 715 485-3194 Pot. Government Ir�t 1 <br /> 1 ❑State Owned 1. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> VILLAGE:Swiss Bass Lake Road <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms 2- A NUM ) <br /> III. BUILDING USE: (If building type is public,check all that apply) 3D-.5-313-0) - OD <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 Bit applicable) <br /> A) 1. x❑ 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.RATE6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 480 480 .63 2 96.6 Feet 99.1 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> i — — - <br /> Septic Tank or Holdino Tank 750 1750 `IMC <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 S ) 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 Siren 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater <br /> pp <br /> [1aO <br /> Issuin <br /> t Si n urs( mps <br /> roved ❑ Owner eel Surcharge Fee) <br /> AverseDetermination yIOVCI � ) <br /> 7 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />