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SANITARY PERMIT APPLICATION COUNTYar <br /> la— loop"PILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITAR ERMIT#IQS5b <br /> (o <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than El 1-70-30) 7 U F <br /> 8'%x 11 Inches In size. Ch k if revisi 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. J <br /> PROPERTY OWNER PROPERTY LOCATION Ci <br /> E(or <br /> Mr,Ye Ya, S C� T N, R W <br /> I Q � d <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 19 2-6 ac AV - N ' <br /> CITY,STATE ZIP CODE PHONE NUMBER RINSER <br /> C �r <br /> AR MJ3 7 <br /> CITY NEAREST ROAD <br /> II. TYPE OF BUILDI G: (Check one) ❑ State OwnedR lowVILLAGE 06 1,JO `1 CC �0 - <br /> ❑ Public M1 or 2 Fam. Dwelling-#of bedrooms Z r <br /> III. BUILDING USE: (If building type is public,check all that apply) c2,0—L4_Z1 "-o)— /OD <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 ❑ RestauranUBar/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. ❑ 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. PERI.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) z Q ELEVATION <br /> 3 0 o '100 ()Z— r HZ_ • 3 Feet 17 Feet <br /> VII. TANK APACITY Prefab. Site Fiber- Exper. <br /> In Qal Ions Total #of Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> INFORMATION New axis'Ln, Gallons Tanks strutted <br /> Tanks Tanks <br /> Septic Tank or Holdina Tank <br /> Lift Pump Tank/Siphon Chamber <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:IN Ste ps) MPIMPRSW No.: Business Phone Number: <br /> IcNpig oP►_INS — 3`t� IS 86L- `�IS <br /> Plumber's Address(Street,City,State,Zip Codel: <br /> 2'1-7&0 WB Wi . S�lSpi3 <br /> IX. COUNTYIDEPARTMENT USE ONLY Issuing tSi u temps) <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e ssue <br /> Surcharge Peel _. <br /> Approved E] Owner Given Initial cH' 13�` <br /> Adverse De rmin tion �1 <br /> X. CONDITIONS OF APPROVALIREASON OR DISAPPROVAL: b <br /> -aa�8 <br /> SiN S <br /> SBD-8398(formerly Plb-87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner.Plumber <br />