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DILH M01 <br /> SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couNTv <br /> STATESANITARERMIT#�2.01C� <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ❑ <br /> 8%x 11 inches in size. c eck I'l revls to previous application <br /> -See reverse side for instructions for completing this application. STATE PLAN IVNUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOC TION <br /> Cano2 Ti tet '% '/4,S 11 T 39 , N, R 14 E (or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 26600 Logan Lane HCR 69 c2.SW NW <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Spooner, WI 54801 715 635-7363 Vol. 428, Pg. 627 <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned VILLAGE Logan Lane <br /> ❑ Public ©1 or 2 Fam. Dwelling,#of bedrooms 3 A <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 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 PER DAY 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADINGRATE 15. PERC.RATE 16. SYSTEMELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 450 720 1 720 .63 3 96.5 Feet 99.4 Feet <br /> VII. TANK CAPACITY Site <br /> in al Ions Total #ofPrefab. Fiber- Exper. <br /> INFORMATION New isffn Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank 0OL 1 Shaw <br /> Litt Pum Tank/Si hon 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:(NoS pa) MP/MPRSW No.: Business Phone Number: <br /> Wade Rujzhotm I A", 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.O. Box 514 SiAen, WI 54872 <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater <br /> Date Issued _ <br /> Issuing Ant Sig ature(No mps) <br /> Approved Sucharge reel <br /> Adverse Determination I aG' 0C) <br /> El Owner Given Initial <br /> 1� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly PIM67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />