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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code co N <br /> ST SANITYPERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �� � CA�8") <br /> 8'/a x 11 Inches In size. I 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 /> PROP RTY OWNER PROPERTY LOCATION h <br /> EIJ '/4 '/4, S 7.5 T (/ , N, R E(or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOC<# <br /> 7771 L-AK DR . Z <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBg�IyyISIONNAM ORCSp�NUMBER <br /> U 0 FS N. 0 2 - ZZ Ca7tS La eSc12 lm (o <br /> It. TYPE OF BUILDING: (Check one) Li <br /> CITY <br /> VILLAGE 1//�v N ESODArDf n <br /> � ❑State Owned N. LK <br /> ❑ Public ISL 1 or 2 Fam. Dwelling,#of bedrooms z A EL Ax Nu B ( ) <br /> Ill. 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 ❑ Re tauranUBar/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.*�<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/gyp(Seepage Bed 21 El mound 30 ❑ Specify Type 41 El Holding Tank <br /> 12 LJ 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 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6 SYSTEM ELEV. 17. FINAL GRADE <br /> REQ IRED(sq.ft.) PROP SED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Q 1( ELEVATION <br /> ..�0 -p1 Z i / �V "' t Feet of0 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank <br /> Lift Pump Tank/Siphon 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 /> Ailiqxlpjs 7Z t.L aA4 15 <br /> P mber's Address(Street,City,State,Zip C e, <br /> Z77&0 w .319, it. s4iv <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date issuedIssuing tsignal o mps) <br /> Surcharge dee) <br /> Approved ❑ Owner Given Initial OCU <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 8 Buildings Division,0mer,Plumber <br />