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on <br /> SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code co JNTY <br /> STATE SANITARY PERMIT# <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than j <br /> ' <br /> 8'b x 11 inches in size. checliire ciontoPapplication C <br /> —See reverse side for instructions for completing this application. <br /> ST, rE PLAN I.D.NUM a <br /> I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. S 3(74— <br /> PROPERTY OWNER PROPERTY LOCATION <br /> oc C.- '/4 '/4, S Z T 3g N R Int o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLO K# <br /> "TZ� C>JL to <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSk4 NUMBER_ <br /> E§igFl,rvlA tJ'r Sb C)Frvc VAipv <br /> It. PE OF BUILDING: (Check one) CITY NEF�� EST ROAD <br /> K1 <br /> State Owned 17 VILLAGE' �� P � <br /> ❑ Public K 1 or 2 Fam. Dwelling,#of bedrooms— PAR EL TTffN�UCM' E ( ) <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 ❑ Ou door Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs _ 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Sei vice 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. KIReplacement 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 3.ABSORP.AREA 4. 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 1 1. <br /> w14s Feet Feet <br /> CAPACI <br /> VII. TANK Site <br /> in al Ions Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> r Holding Tank d <br /> Lift Pum Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of t onsite sewage system shown on the attached tans. <br /> Plumber's Name(Print): Plumber's Signature: o Stamps) 3W/MPRSW No.: Business Phone Number: <br /> 3343 11 i5 _ gZ <br /> Plum is Address(greet,City,State,Zip Code): ^ <br /> I a5 9X Z Gl W. pO( <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> El Disapproved Sanitary Permit Fee(Includes Groundwater aessue Issuing le lSi net ( ps) <br /> Su\rch fW <br /> SVFee) <br /> Approved El Owner Given Initial 0, /_I�_C� <br /> Adverse Determination `1 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,0 1 <br /> ner,Plumber <br />