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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code cou Tv <br /> STA E ANITAeYPERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than � J 7 <br /> 8%x11 Irlche3 In SIZe. heck if r Psion to previous application <br /> -See reverse side for instructions for Completing this application. STA E PLAN D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. 77 . <br /> PROPERTY OWNERPROPERTY LOCATION <br /> Z 0 /Yf �� '/4 ''/a, SaG T3 7, N, R/Y E(O W <br /> PROPERTY OWNER'S RE <br /> MAILING D SS LOT# BLOC # <br /> v� (.), X 5 o �� e J C� <br /> CITY,ST4TE ZIP CODE OHONE NUMBER SHDDrOMO -NAME OR CSM NUMBER <br /> �Ioern/A1 t°N -elL / 1 <br /> II. TYPE O BUILDING: (Check one) GILL r NEAR ST OAD <br /> ❑ State Owned O VILLAGE WN - � /ee fg o/ <br /> ❑ Public I/�il1 or 2 Fam. Dwelling-#of bedrooms 'PARCEL TAX NUMBER(S) <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, TYP//Ell 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 ❑ Specity Type 41 V 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 PE2.ABSORP.AREA 13.ABSORP.AREA 4. LOADING RATE 5. PERC,RATE 6 SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> /;7 _ R DAY 0 Feet Feet <br /> Vii. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Expp- <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank Ddd odF �"�"`� <br /> Lift 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(Pri t): Plumber's Signature:(No Stamps) *MIOMPRSW No.: rBu;siness Phone Number: <br /> G✓�e v s��% G✓� �-,- .��1 is <br /> Plumber's Address(Street,city,State,Zip Code): <br /> 7l ) /AjQX jj;- <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee llncludes Groundwater ae ssue IssuingA t ignet u $Ip ps) <br /> surcharge Fee) <br /> Approved ❑ Owner eDetermiin �..fl"j <br /> Adverse Determination �J Com' <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,O ner,Plumber <br />