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Gilf kJIV <br /> ��r, <br /> SANITARY PERMIT APPLICATION <br /> f.=LIl IR In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> A//i/ )4 e <br /> ST E SANITARY P RMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8'r4 x 11 inches in size. ck »> <br /> heif revision to Drevioua application <br /> —See reverse side for Instructions for completing this application. ST TE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> evGP S ♦ n c, '4 4SE '/4,S J TS9N R J E(or)19) <br /> PR PARTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> /{T. l ox /v�2Y /✓i4 /VA <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 57 oon er , �JJ Sy�a/ *A <br /> II. TYPE OF BUILDING: (Check one) ET <br /> CITY NEA EST ROAD <br /> State Owned ET VILLAGETOWN U 0 <br /> ❑ Public Of or Fam. Dwell ing—#of bedrooms PARCELTAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo `J <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 ❑ 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 /> 11Seepage 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 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6 SYSTEM ELEV. 7. FINAL GRADE <br /> O REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 7 S4 V,76 C 3 7AIA T• 7 f Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New <br /> xis <br /> Gallons Tanks Manufacturer's Name Concret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 10,70 J J <br /> Lift Pump Tank/Si hon Chamber .7 <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 ) MP/MPRSW No.: Business Phone Number: <br /> PIe'\ Sta '? 06b 'JlS �110�-,1(oDj <br /> Plumber's Address(Street,City,State,Zip Cope)//--eat, Lc !te -- ouc� /'�o„eiT <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanita Permit Fee(Inclueee Groundwater ate IssuedIssuing en Signat r o t mps) <br /> �/ I Surcharge Feel <br /> p[J Approved ❑ Owner Given Initial �D_`d <br /> V\ Adverse Determination 1 <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBU6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,0 net,Plumber <br />