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.7— 0 SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couNTv <br /> — J3u r <br /> • _ STATE SANITARY'''RRRERMIT# •)'�/}a <br /> -Attach complete plans(to he county copy only)for the system,on paper not less than C�'(� ; �1 <br /> 8%x 11 Inches In size. ❑ Checkifrevls to previous epplicatiort <br /> –See reverse side for instri.ctlons for Completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION + <br /> Y4 't/a,S 16 T , N, R E(o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> Q0 - c G.014 t. 1.0-r 6r; <br /> CITY,STATE ZIP CODE I PHONE NUMBERS I C�`C <br /> II. TYPE OF UILDING: (C eck ohne) CITY V NEAREST ROAD <br /> ❑State Owned VILLAGE S C.KSo� CO RD . C <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms <br /> 111. BUILDING USE: (If building type is public,check all that apply) I a, _ air--aa-sem <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: (Che k 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 /> 11Seepage Bed 21 ElMound 30 ❑ Specify Type 41 ElHolding Tank <br /> 12 9 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.A 3SORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> RE UIRED(sq.k.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./Inch) Q ELEVATION <br /> 300 0 �() fv2 3 96-0Feet JW-5 Feel <br /> VII. TANK CAPACITY Site <br /> INFORMATION in al Ions Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> New !stingGallons Tanks Concretestructed glass App. <br /> Tanks Tanks <br /> Se tic Tank or Holdina Tank <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume r sponsibi lity 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 /> C' 3t47t 7rs 866- 4157 <br /> Plumber's Address(Street,City, tate,Zip Code). <br /> 2.11Q) w W66TEC l . Sg8113 <br /> IX. COUNTYIDEPARTMEA T USE ONLY <br /> Lj Disapprove Sanitary Permit Fee(Includes Groundwater e e asue IssWnig(gent Sign a(No Stamps) <br /> Surdharge Fee) __I) <br /> Approved El owner Give Initial i41 I 'F,p-1 L/Z–'p(// Q ' <br /> A v Deermin t '�1 00 <br /> X. CONDITIONS OF APPR VAL/REASONS FOR DISAPPROVAL: -v-- lr> G <br /> �Yrl,oi,(-, -C, b 4," lett 39'5;q' fro^ aelaw �ro� �u <br /> Slap, ek" ,ON sett"-o�,44- <br /> SBO-6398(formerly PlbE7)(R.11/ 1 DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />