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- SANITARY PERMIT APPLICATION <br /> COUNTY <br /> 'in r" M In accord with ILHR 83.05,Wis.Adm. Code <br /> STATE SANITARY PERMIT# p <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than cif? <br /> 8'k x 11 inches in size. ❑ Check if revision 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. 17S- 1_30n <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Gene Halvorson /t )Ya ''/a, S 20 T 38 , N, R 17 ff(or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOC<# <br /> 200th Irene Street <br /> CITY,STATE ZIPCODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Bakersfield, CA 93305 805 328-9935 gc�-NW-3Lr <br /> It. TYPE OF BUILDING: Check one CITY p NEA EST ROAD <br /> ( ) State Owned O VILLAGE: Daniels B ongren Road <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms-3-- RCELTAx NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) -�uk - O -coin <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: (Checkonlyone in line A. Check line B if applicable) <br /> A) 1. ❑ ck� <br /> New 2. LReplacement 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 /> 13Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER 7 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 5. PER'.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.if (Min./inch) ELEVATION <br /> 450 563 570 .79 NA 98.9 Feet 101.5 Feet <br /> CAPACITY <br /> VII. TANK n allons Total Site <br /> INFORMATION #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> New xistin Gallons Tanks Concrete structed glass App. <br /> Tanks Tanks <br /> Se tic Tank or Holdin Tank 1,0l <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 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.O. Box 514 Siren, WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> tom/, d El <br /> Disapproved Sanitary Pa it Fee(includes Groundwater Date IssuedIssuin A nt ign t e N amps) <br /> P ?i,5ApproveOwner Given Initial ��O <br /> ge Fee) ^� / <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-8398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Ow or,Plumber <br />