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R� SANITARY PERMIT APPLICATION <br /> ����) In accord with ILHR 83.05,Wis.Adm. Code couN of <br /> STATE SANITA PER IT$ <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �' � iso <br /> 8'h x 11 inches in size. ❑ C ieck if revision to previous application <br /> -See reverse side for instructions for completing this application. STAT PLAN I.`D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Duane Hazelton /4 '/4, S 28 T41 , N, F 16 1 (or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT fl BLOCK <br /> P.O. Box 218 6 & 7 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Danbury, WI 54830 715 866-8857 Original Townsite of Danbury <br /> Li CITY s NEARE T ROAD <br /> It. TYPE OF BUILDING: (Check one) <br /> ❑ State Owned C3 VILLAGE: Swiss <br /> ' First Street <br /> ® Public ❑1 or 2 Fam. Dwelling-#Of bedrooms— PARCELTAX N MBERS) <br /> III. 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 11x❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Servi a 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. x❑ 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 ❑ SpecityType 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 51 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 /> 400 375 376 1.2 KA 7'8 Feet Mound 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- reel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank --- k950WCP <br /> Lift Pum Tank/Siphon Chamber 800 -- 800 1 i Skew <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached pi ins. <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 /> Disapproved Sanitary Per t Fee(includes Groundwater aessue Issuing g tsigna ( o m(p�s) <br /> Y c�}r9e Fee) ^�-�.,i— �, S <br /> Approved ❑ Owner Given Initial ���C�� <br /> Adverse Determin tion <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Own r,Plumber <br />