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���-� SANITARY PERMIT APPLICATION <br /> ���� In accord with ILHR 63.05,Wis.Adm.Code co NTY <br /> B� - f� <br /> ST �I ftN�l�T� Y PERM# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than k � r �j 3� <br /> 8'f�x 11 inches in size. <br /> Check if revision to previous application <br /> wee reverse side for instructions for completing this application. sT E PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PR PERTV OWNER PROPERTY LOCATION <br /> �jr-e'u ��5"ov. ,�W '/s/(/GC/'/a, S � T�t3 , N, R / -E�er <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOC # <br /> �� ) � s1'o�e d �l \ vL 1 <br /> CITU,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> t✓c Lii4 Ltl'r' S - /J 6 CS"^ 1/ 14Q- )R2:- <br /> II. TYPE OF BUILDING: (Check One) CITY NEA EST ROAD <br /> ❑ State Owned VILLAGE: ,S'Cti,.}� �n �d , <br /> ❑ Public �1 or 2 Fam. Dwelling-#of bedrooms PA L AX NUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) 1. 70- (.f 1 IC, ��) � O <br /> 1 ❑ ApVCondo / <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Out oor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Re tauranUBar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Ser ice Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ 0th r: 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 ❑ 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 /> REQCUL1REcDy(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) o� ELEVATION <br /> G Z � ! .3 �-- �, 0 Feet Q7 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdin Tank � �/PS$Y- <br /> LittPum TanWSi hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached tans. <br /> Plumber's Name(Print): Plu tier's Signature: mps) MP/MPRSW No.: Business Phone Number: <br /> �el. � 'l-C�� (tel 7s�' Sto(�' <br /> lumber's Addr (Street, ity,Stale,Zip Code): / <br /> s �, � Ccs <br /> IX. COUNTY/DEPARTM NT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Ilnciutles Grountlwater a e ssue Issuin n Si at re( o Stamps) <br /> rrrr����yyyy gur�ergo Fee) u � <br /> L.R�Approvetl ❑ Owner Given Initial �� 1 _l_G� <br /> Adverse Determination lJ 1 / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Ow er,Plumber <br />