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SANITARY PERMIT APPLICATION COUNTY <br /> r:jT01jL,,HFR In accord with ILHR 83.05,Wis.Adm. Code <br /> ^•^� BURNLTT <br /> ERMIT#1q0l <br /> 0 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than C 151GSTATE S,PNITARY�(o7T 7� <br /> 8%x 11 inches in size. <br /> Check if revisi 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. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> JOHN gIJANS ON SE Y4 NV/ t%,S 13 T39 , N, R 14 ok W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 231 2nd <br /> CITY,STATEZIP CODE I PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> EXCNLSIOR DIP) 55331 612 4.74 218 <br /> Lj It. TYPE OF BUILDING: (Check one) ❑ State Owned O CITVILLAGE: RUSK NEARESLROIL NL <br /> ❑ Public ©1 &2 Fam. Dwelling-#of bedrooms 3 A u ) �11�'uu hhVV11VV LL1l <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 <br /> -�only one in line A. Check line B if applicable) <br /> A) 1. ❑ New 2. I11 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 M 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 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 45O REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 615 620 .72 -43 92.7 Feet 96.1 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Tolal #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New istin Gallons Tanks oncret glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 1000 1 'NIESERS <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installatio of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Sign re:(No Stamps) WIMPRSW No.: Business Phone Number: <br /> rt;L FERGUS 0 3393 ?15 )635-7482 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> HCR 59 BOX 478d SPOONER, 'c7I. 54801 <br /> IX. OUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Grounawater Date IsTuirIs In Agent Sig re(No Stamps) <br /> pproved ❑ Owner Given Initial 1 ocSurcharge Fee) _q <br /> A v rm'n tion `O�' "� � ` O <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBO-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />