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.. SANITARY PERMIT APPLICATION COUNTY <br /> r�aa-I IR In accord with ILHR 83.05,Wis.Adm.Code <br /> !tt'l r <br /> STATE SANITARYPERMIT �7�� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 1:1(12r?) 7 <br /> 81/2x 11 inches in size. Check if revision to previous application <br /> -See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTYOWNER / PROPERTY LOCATION <br /> h f A1,F '/a S %, S T 410, N, R /rE (Dr <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> ap NA <br /> CITY,STATEVZIPCODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> / SS/ ( - 6P. /6t <br /> . TYPE OF UILDING: (Check one CITY NEAREST ROAD <br /> ❑ State Owned O VILLAGE 4G�Joh SCi 6 est deal- <br /> fFNL;OWN OF' <br /> ❑ Public >a1 or Fam. Dwelling-#k of bedrooms a PARCEL TAX NUMBER(S) <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 ❑ 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. XNew 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 RrSeepage 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 /> REQUIRED(sq.ft.) PROPOSSED(sq.ft.) (Gals/day/sq.ft.) <br /> (Min./inch) �7i �- ELEVATION <br /> 300 �}p U 6 3 �i¢ � � Feet g 6� Feet <br /> VII. TANK CAPACITY Site <br /> in alions Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank D 7-rO / -r a cq cye r <br /> Lift Pum Tank/Si hon Chamber El El <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 Stamps) MP/MPRSW No.: Business Phone Number: <br /> aAaCC S. /3etfo 1✓ /t9P6473 7/1 <br /> Plumber's Address(Street,City,State,Zip Code): r- / / <br /> e P/le eta/ /U. Ve/� tet, A// . ,fy�l� <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E] Disapproved Sanitary Permit Fee(Induces Groundwater Date IssuedIssuin A ant Sign ure(N Stamps) <br /> Approved ❑ Surcharge Fee) <br /> Owner Given Initial W <br /> AdverseDetermination ISO <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 />