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�t el✓,np <br /> 010.c^ SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> T S NITARRMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than OOl$ <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.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. S9f� <br /> PROPERTY WNE)/R PROPERTY LOCATION <br /> e /�cc r ' '/a 5 '/a, So2S T3 , N, R / E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> oZ 3 6Z0/ — <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 12s r f Sf' `'U <br /> El <br /> If. TYPE OF BUILDING: (Check one) StateOwned VIS VILLAGE (,.J' o o AREST ROAD <br /> 7 <br /> �^y r D. 22W <br /> ❑ Public 911 or 2 Fam. Dwelling—#of bedrooms PARCELTA NUMBER( ) <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 ❑ RestauranUBar/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 <br /> kk(only one in line A. Check line B if applicable) <br /> A) 1. El New 2.,g 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 4 Mound 30 El 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 72.ABSORP.AREA 3.ABSORP.AREA 4. LOADINGRATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 2REQUI�RED(sq.ft.) PR�QJPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 30� ' ✓ 0 µ / 17Feet Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xistin Gallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Se tic Tank or Holdino Tank X low <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:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> T� ,fid- 331L? <br /> Plumber's Address(Street,City,State,Zip Cod <br /> G� Z45,, 7 e <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater ate IssuedIssui ent Sign to (No tamps) <br /> Approved ❑ Owner Given Initial Surcharge Feel <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />