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ccurap <br /> .,in-WESANITARY PERMIT APPLICATION <br /> r� R In accord with ILHR 83.05,Wis.Adm. Code co NTY <br /> ST E SANIT RY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less thanfy� 1�yC'I� <br /> 8'%x 11 inches in size. (J1� � t <br /> Check if revision to previous a plication <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 /> _1 C4_Ca y n utsT SE'/4 SE %4, S A-7 T 40, N R 14 &(w4 W <br /> PROPERTY OWNER'S MAILIN DDRESS LOT C, BLO K# <br /> 3►,r�tca � <br /> CITY,STATE ZIP CObDE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> oOM1ef uJr S.`f FCO) LJ <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned O VILLAGE be Tg �01 NEA ES;h�ORIA{� <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms z- PARCAN OF TAX NUMBERl ) <br /> III. BUILDING USE: (If building type is public,check all that apply) ct& <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Out oor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Ser ice Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Oth r: Specify <br /> IV. TYPE OF PERMIT: (Checkonly one in line A. Check line Bit applicable) <br /> A) 1. ElNew 2. XReplacement 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 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE5. 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 -/Z5 lci Z • 7 1 /rJo,- ha.7 Feet 'T_153 Feet <br /> VII. TANK CAPACITY Site I n allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel Plastic <br /> Tanks Tanks e structed glass App. <br /> Se tic Tank 8ctp 00 / <br /> Lift Pump Tank/Si hon Chamber <br /> VIII. RESPONSIBIL TY ATEMENT <br /> 11 the unde a ' ity for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's N o^X A7od PI mber' Signatur No Stamps) MR/MPRSW No.: Business Phone Number: <br /> W Y oU <br /> Plumber's Ad .£IHip ip Code): !•3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Include�Groundwater��I�ssujnj <br /> tSign a(No Si mpsI <br /> *Approved ❑ Owner Given Initial SurchaAdver eDetermination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />