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SANITARY PERMIT APPLICATION <br /> �■■,E` COUNTY <br /> t�'IIIr_Illr�WS In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE RMTr <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ±��J (�,J� GG��JJ22 <br /> 8%x 11 inches in size. ❑ Check if revision to previous application <br /> –See reverse side for instructions for completing this application. STATE PLAN I.D.N R <br /> I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORM TION. <br /> PROPERTY OWNER � ^ PROPERTY LOCATION <br /> "n <br /> \ J� t /4 �4, S 3 T 3q N, R I E (or)W <br /> PROPERTY OWNER MAILING A RESSLOT# BLOCK# <br /> p tr�bo.J oAD <br /> CITY,STATE ZIP CODE PHONE NUMBER SUB IV 10 AME OR CS�MBEg 0 <br /> c7� // YS�i X s j fT <br /> Ii. E OF BUCITY NEAREST ROAD <br /> ILDING: (Check one) ❑ State Owned ❑ VILLAGE:9�'TOWN OF' bf` E•'6 ewvwA L-0ty-f- <br /> ❑ Public X1 or 2 Fam. Dwelling–#hof bedrooms-7=L PARCEL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) — 203 <br /> — ©/ <br /> 1 ❑ ApUCondo l� <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. X 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 12.ABSORP.AREA 13.ABSORP.AREA 14. 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 /> ,300 A I LC S o� h `i5.-7 Feet <C?(o.`J Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank o -756 uDI <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assUegepponsibility for installation of the nsite sewage system shown on the attached plans. <br /> Plumber's NOENirigtk� & EXCAVAT oRb is Si ature:IN tamps) MR/MPRSW No.: Business Phone Number: <br /> 1NPn Cou Line <br /> Plumber's Address( ode): <br /> (7i5) 5- �i <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fe (Includes Groundwater a e ssue Issuing ent n ture o S mps) <br /> Approved F-1owner <br /> Fee) <br /> Owner Given Initial 450 t �Od <br /> Adverse Determination ��JJvv + "y <br /> 71 <br /> X. CONDITION`?OF PPROVA REASONS FOR DISAPPROVAL: <br /> �t15 cST�tu'e is r/'�si�e�&IG(,,- del /,� je 4t. 49 as,q fi ( , <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />