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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNT f <br /> STATE SANITARY RMITl— �p„ <br /> —Attach complete plans(to he county copy only)for the system,on paper not less than ()776 To( W O� <br /> 8Ys x 11 inches in size. C Iov. - 2_ t4 Md 1:1Check if revisio to previous application <br /> –See reverse side for instr ctions for completing.this application. STATE PLA I.D.NUMBER <br /> I. APPLICANT INFORMATI 3N–PLEASE PRINT ALL INFORMATION. 4– <br /> PROPERTY OWNER`` 's/ 1 S 4V G.. PROPERTY LOCATION '/ -A0 3L <br /> tq t116,,3 A,A 4 /11 s� '/e gswn t e G C a A(UJ% 7'/a, S �0 T 1 0, N, R El(0 W <br /> ROPERTVOOWNER'S OMAILING VR SS LOT# 14 � BLOCK# I <br /> CITY,STATE <br /> SSTTAATE �QCr)//CC// ZIIPr/CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> il 91 rrl s'r,�,� bla y.� -dsaCITU II. PE OF BUILDING: (Ceck one) VILLAGE: <br /> � a ' ) ICK <br /> NEAST ROAD <br /> �J 1 / <br /> ❑ State Owned ❑ VILLAGE La 4ow OF: Q�d NEAP <br /> N U$ {L L 7 �d <br /> ® <br /> Public or Fam. Dwellil of bedrooms— PAR ELTAX NUMBER(/n) _ I // <br /> 111. BUILDING USE: (It built ling 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 X Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. N 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 Perm t was previously issued. Permit# Date Issued <br /> V. TYPE OF SYSTEM: (Cf eck only one) <br /> Non-Pressurized Distriblu on Pressurized Distribution Experimental Other <br /> .(. �t <br /> 11 �Seepage Bed �. 21 [1 Mound 30 El Specify Type 41 El 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 SYSTE161 INFORMATION: <br /> 1.GALLONS PE2. BSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> ,Q R DAY REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft (Min./inch) /7t` ELEVATION <br /> /Bow pp0 241 O © S Feet JfOO.sd Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 6 uc w <br /> Lift Pum Tank/Si hon Chamber 60 (L e w <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume esponsibility for installatioo of the onsite sewage system shown on the attached plans. <br /> Plumber's Na a(Print): PI be 's S nat e:(Na Sta ps) MP/MPRSW No.: Business Phone Number: <br /> IIIk 157we 33 6'6 /f Y7d'a s- <br /> Plumber's Aass($treat,City, tate,Zip Code). <br /> o 41 <br /> IX. COUNTY/DEPARTME USE ONLY <br /> ❑ Disapprov d Sanitary Permit Fee (Isurcharge <br /> e I")water a e ssue Issuing A nt Signature(No Stamps) <br /> Surcharge Fee) <br /> Approved Owner Given Initial <br /> Adverse termination <br /> NDITIONS OF APP VAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />