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14HR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTYBugfM1` <br /> �• � STATE SANITARY PERMIT#1bti✓4o <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ C(��� <br /> 8'fx11inches insize. checkifr siontopreviousapplication <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 /> Whi,5peAinq P2nez NW Ys Y4, S 12 T 37N, R18 E (Or)ly <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 11050 WhigspeAinQ PCneh Road <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> FAeden2c, W7 54837 715 327-4701 <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned VILLAGE:Taade Lahe <br /> Fnn Whir enin P2nea a <br /> X] Public ❑1 or 2 Fam. Dwelling-#of bedrooms— PARCEL TAX NUMBERIS) <br /> r <br /> III. BUILDING USE: (If building type is public,check all that apply) ��j F-D <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 amn d yLni to <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. ❑ New 2. Q 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 PER 51 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC. RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 800 1260 1260 .65 4 1 89.9 Feet 92. 1 Feet <br /> VII. TANK CAPACITY Site <br /> in 11 is <br /> Total #of Prefab. Fiber- Exper. <br /> INFORMATION New tstin Gallons Tanks Manufacturer's Name ConcreteCon- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> F1 H <br /> Septic Tank or Holdin Tank <br /> Litt 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 RubehoPm 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.U. Bax 514 _qiAen. WT ;JR79 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved SanitaryPermit Fee(Includes Groundwater Date IssuedIssui ent Signature(No Stamps) <br /> roved F-1Owner Given Initial yam{{- n surcharge Fee) <br /> )4t-P <br /> Adverse Determin tin "T <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 />