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SANITARY PERMIT APPLICATION <br /> V AR C <br /> OUNTY In accord with ILHR 83.05,Wis.Adm.Code <br /> ANITA PERMIT#tZLl(iqS—Attach complete plans(to the county copy only)for the system,on paper not less than q ^8%x11inchesinsize. If rev ntopreviousapplication <br /> —See reverse side for instructions for completing this application. LAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> 12IR <br /> /4 '/4, S a T qO, N, R IL E (or(W <br /> PROPERTYOWN R'S MAILING ADDRESS LOT# BLOC # <br /> 13 q Ccc Rn _ .L_2 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> \41 . 514s3o 5 . z p <br /> II. TYPE OF BUILDING: (Check one) El CITY NEAR ST OAD <br /> State Owned VILLAGE r/yt nw <br /> ❑ Public ®1 or 2 Fam. Dwelling #of bedrooms A L I IX NUMBERS) La <br /> III. BUILDING USE: (If building type is public,check all that apply) µ0 - 16. 02.. bZ�{oo <br /> 1 ❑ ApUCondo l <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Res auranUBar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Seri Fice Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Oth 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 MSeepage 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 7 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PER' RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Iso Z15 32 . 3 Z•6 Feet S Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of. Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concret Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank ISO E K <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 p ans. <br /> Plumber's Name(Print): Plumber's Signature:(No tamps) MP/MPRSW No.: Business Phone Number: <br /> 1cHAR� DYKI/JS 3` 7 �lS $(06 41S? <br /> Plumber's Address(Street,City,State Zip Code): <br /> 711&0 X ,I' 14665? Wl- SyS`t3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes <br /> roun water Date IssuedIssui gent Si re(No Stamps) <br /> Approved ❑ Owner Given Initial �I/' 1Tn-/rye 7—/S-9S <br /> Adverse Determination '�P <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SB0.6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owr er,Plumber <br />