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SANITARY PERMIT APPLICATION <br /> CCUNTY <br /> In accord with ILHR 83.05,Wis. Adm.Code <br /> 4 I-It e-�-f <br /> ST TESANITA YPERMIT# f� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 81/2x 11 Inches In size. heck if revision to previous 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. S?,s--,;L D /� <br /> PROPERTY OWNER PROPERn LOCATION <br /> b td�� E;-IGItsu Pt%S99 tit, s3 ' T3 , R /(o ) W <br /> PROPER OWNER'S MAILING ADDRESS LOT# LI BLOCK# <br /> P+. ! BOX 13-7 w <br /> -.T- <br /> C17,STATE ZIP CODE PHONE NUMBER SUBD VISION NAME OR CSM NUMBER c-c�, <br /> Tine 6 {7'11'1 So � 1141 l/K YG Ci _ <br /> II. TYPE OF B ILDING: (Check one) CITY NEA EST ROAD <br /> ❑State Owned l7 VILLAGE: = <br /> or a Ie' IV <br /> ❑ Public K 1 or 2 Fam. Dwelling,#of bedrooms PAR EL TAX NUMBERS) <br /> III. BUILDING USE: (If building type is public,check all that apply) C)W —9IJ O --c)t--y o <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 ❑ 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 /> 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 N 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 13.ABSORP.AREA 14. LOADING RATE 5. PERC. RATE . SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Z/15-0 <br /> �_ �_ Feet —meet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New ix <br /> Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank o oldin Tan <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility Tr installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): P tuber's Signatu :IN Stamps) MP/MPRSW No.: Business Phone Number: <br /> Nets KD$� <br /> Plumber's Address(Street,City�t1te,Zi�Code): W 5 <br /> WKS' L±2 <br /> IX. COUNTYIDEPARTMENT USE ONLY YJ <br /> ❑ Disapproved I Sanitary PerTit Fee(Includes Groundwater a e IssuedIssuing,IssuinIS' n t re N amps) <br /> ,Approved F-1Owner Given Initial `�[\ 'c Fee) -_ `0 �� 1 <br /> AdverseDetermination _$ 061" <br /> I v C7�, <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,0 ner,Plumber <br />