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SANITARY PERMIT APPLICATION <br /> DIS IR In accord with ILHR 83.05,Wis.Adm.Code couNTv <br /> mss• _ STATWNITA PERMIT#^I' <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 6 o' ( <br /> _ <br /> 8%x 11 inches in size. ❑ Check if on 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. 1 �1016 <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Jerry Christenson '/4 SW '/4, S 33 T 38, N, R 18W E(or W - <br /> PROPERTYOWNER'SMAILING ADDRESS LOT# / BLOCK# <br /> 1941 240th St 1W <br /> CITY,STATE ZIP CODE IPHONENUMBER SUBDIVISION NAME OR CS NUMBER � " �, <br /> St.Croix Falls,W 54024 715- 83-113 'M }}an �(Lb, <br /> II. TYPE OF BUILDING: eck one) 1 0 CITY NEAREST ROAD <br /> ( State Owned VILLAGE <br /> ❑ Public [A 1 or2 Fam. Dwelling-#of bedrooms 2 ORRY NUMBER(S) <br /> 111. BUILDING USE: (If bulk ling type is public,check all that apply) <br /> 1 ❑ Apt/Condo <br /> 2 ElAssembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestaurantfBar/Dining <br /> 4 ❑ Church/School NA 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: (Ch ickonly one in line A. Check line Bit applicable) <br /> A) 1. ❑ New 2. KI Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Perm t was previously issued. Permit# — Date Issued <br /> V. TYPE OF SYSTEM: (Ct ieck only one) <br /> Non-Pressurized Distrib ition Pressurized Distribution Experimental Other <br /> 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41)qE 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.A BSORP.AREA3.ABSORP.AREA LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> RE UIRED(sq.tt.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 00 N perc do a due to la[4. <br /> k of roo I I Feet Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #ofPrefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank 200d <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume I esponsibility for Installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): r' ignatur : No mps) MP/MPRSW No.: Business Phone Number: <br /> Rodney Hendrickson PRS03470 U15751-3335 <br /> Plumber's Address(Street,City, tate,Zip Code: <br /> Box 261 Dresset, wi qA 09 <br /> IX. COUNTYIDEPARTMEP T USE ONLY <br /> ❑ <br /> Disapprove Sanitary Permit Fee(includerg roounndwater Date IssuedIssu ent Signat oStamps) <br /> Approved Owner Given Initial I <br /> Adverse of termination ..J J <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11 88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />