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SANITARY PERMIT APPLICATION <br /> E <br /> A� <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> ti <br /> STATESANIRY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 41-D is l <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. <br /> PROPERTY OWNER � PROPERTY LOCATION <br /> rc,r� Tr Icr�[QS�w�t '/4 /s, S 3S T 4t4, N, IS W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOC # <br /> 12.73 od Dilk. Z <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> AoP1"fi6L&:An $IzfVIZ 47'b �)1 <br /> CITY NEAR ST RO D <br /> It. TYPE OF BUIL ING: (Check one) ❑ State Owned E03 VILLAGE: <br /> ❑ Public �q1 or 2 Fam. Dwelling-#of bedrooms PARCEL TAX NUMBER(5) <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Res aurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1.10 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit# Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11Seepage Bed 21 ❑ Mound 30 El SpecifyType 41 ❑ Holding Tank <br /> 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER F7 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) I ELEVATION <br /> 450 &43 4.16 7 mer A 94 Z Feet I 94,L Feet <br /> VII. TANK CAPACITY Site <br /> IT allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank op*h� <br /> Lift Pump Tank/Siphon Chamber <br /> Vill. RESPONSIBILITY STATEMENT <br /> I,the undersigned,a u esponsibility for installation of the onsite sewage system shown on the attached pans. <br /> Plumber's NelrnMPrjnt)$ 66AVATIONPlumber's Signature:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> NCR 59 3393 <br /> Plumber's A Petry,S "Code): <br /> IX. COUNTYIDEPA r TMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee(Includes Groundwater Date ssue Issuin Sig e r (N tamps) <br /> Approved styyharge Fee) <br /> ❑ Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SB0.6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Ow er,Plumber <br />