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SANITARY PERMIT APPLICATION <br /> SIL R COUNT <br /> Ya <br /> accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITARYPERMIT# r, <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than (N q1 �y� 6 <br /> 8'%x 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 /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Vgw EM '/a '/a, S �` T`f 0 , N, R So E (0 W; <br /> PROPERTY OWNER' MAILING ADDRESS LOT# BLOCK# <br /> 7211 f0m sT'E v 70. <br /> CITY,STATE I ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> gto 1. 1,94830 /S - 9 Id1) RES <br /> II. TYPE OF BUILDIN : (Check one) CITY NEAREST ROAD <br /> State Owned VILLAGE : ND R 0 <br /> WN OF' <br /> ❑ Public or 2 Fam. Dwelling—#of bedroom PARCEL TAX NUMBER(b) <br /> 111. BUILDING USE: (If building type is public,check all that apply) C;zc)— <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 2.14Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only (023).S <br /> p Existing System Existing System <br /> B) A Sanitary Permit was previously issued. Permit# (O/S I 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 ElHolding Tank <br /> 12 4 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 16. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.f.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION LEVATION <br /> qvv - � Feet Q6•0 <br /> Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Hold! Tank �'' <br /> Lift Pum Tank/Si hon Chamber <br /> Vlll. 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 /> 1 �zn 'lr✓s 3 q2� 6 - 15 7 <br /> umber's Address(Street,City,State,Zip Cod <br /> 27-760 44w4 35 3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater ae IssuedissuingAgent Sign tura No amps) <br /> Approved Ff�l -1owner Given Initial �rx fleF�) <br /> AdverseDetermination L-PP \\�—� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety B Buildings Division,Owner,Plumber <br />