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_DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm. Code J�ur <br /> �• � STATE SANITARY RMIT#�SCYS'] <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ❑ �(o�s� / <br /> 8'h x 11 Inches in size. k if revision 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 /> Doug EdwaAdz '/4 '/4, S 18 T 40 , N, R 16 E(or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 28798 Wezt VePtow Riven. Road 10 <br /> CITY,STATE ZIP CODE I PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Danbury, WI 54830 775)656-3266 Pine Ridge Subdivision <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ❑State Owned VILLAGE: Upktand W. yeftow Riven Road <br /> [] Public ®1 or 2 Fam. Dwelling,#of bedrooms Z NUMBER(S) <br /> 111. 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 only one in line A. Check line B if applicable) <br /> A) 1. ❑ 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 PER2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED AREA <br /> ft.) PROPOSED(sq.ft.) <br /> (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 30071 480 480 .63 3 1 95.1 Feet 97.5 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 750 750 <br /> Lift Pum Tank/Siphon hon Chamber 500 ,� <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:(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Rubshotm l/�pL� 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): IV <br /> 24702 Lind Road P.O. Box 514 Siren, WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> YA❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e Issued Issuing Agent net IN S ps) <br /> 1� Surcharge Fee) <br /> Approved ❑ Owner Given initial 'O_�/ n <br /> AdverseDetermination • I `I <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 8 Buildings Division,Owner,Plumber <br />