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SANITARY PERMIT.APPLICATION oo <br /> UNTY <br /> r�7a.ttnttn In accord with ILHR 83.05,Wis.Adm. Code C���� <br /> STA ES.JJANI)IL , PERMIT#�L� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than oW0�!y`^J\ �"��rS^ U - <br /> 8%x 11 inches in size. heck if revision to previous aDPlicat!on <br /> -See reverse side for instructions for completing this application. STA E PUN I.D.D.NuMe�� <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. `= �� <br /> PROPERTY OWNER PROPERTY LOCATION <br /> W td0 $AR 51M pN oep,50" '% %, s in T , N, E(O W <br /> PROPERTY OWNER'S MAILING DRESS LOT# / BLOC # <br /> 20 OCI CD Rcrt <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMB <br /> 't o W l_ of is 35- CSS-, uS ERa \ <br /> 11St <br /> . TYPE OF BUILDING: (Check one) CITY NEAR ST ROAD <br /> at@ OWned VILLAGE t.l�i K {v • )C.� ..( <br /> � <. RD, <br /> .Public ❑1 or 2 Fam. Dwelling-#of bedrooms— JARTAX BER(b) <br /> III. BUILDING USE: (If building type is public,check all that apply) ,r•�\t[ _ '© _ o I �a p <br /> 1 EJApt/Condo �9 L v <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Out oor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Res auranUBar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. ❑ New 2.,,D<Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit# Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 X Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 15. PERC.RATE 16. YSTEM ELEV. 7. FINAL GRADE <br /> V�f REQUIRED(sq.ft.) PROPOS�EID(sq.tt.) (Gals/day/sq.ft.) (Min./inch) 00.$ L NATION <br /> L Q 1ILLi J �Z 1� . / ,5 Feet � ��6 Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdin Tank �0 <br /> Lift Pum Tank/Si hon Chamber wo I — Soo ) <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached pl ans. <br /> Plumber's Name(Print): Plumber's Signature:( o St ps) MP/MPRSW No.: Business Phone Number: <br /> c Rn Ind 3 yZ-6 5 $66 S <br /> P umber's Address(Street,City,State,Zip Code): <br /> 2.7-7bD I&V 35 VE05TV9 Wl- —S2913 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Pe mit Fee(Includes Groundwater a e Issued Issuing t na r (No tamps) <br /> rche(ge Fee) <br /> Approved ❑ Owner Given Initial f.� �!,i <br /> AdverseDetermin tin �.l <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.OB/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Ow t <br /> r,Plumber <br />