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7 ayy) <br /> SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code Cou (� <br /> STA SANITARY PPERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than �O)i aLD <br /> 8'%X 11 Inches In size. heck if revision to previous application <br /> —See reverse side for Instructions for Completing this application. STA E PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER 1. PROPERTY LOCATION 4('C� <br /> #,4PI' 1� u 4-f- nl a) riw'/a, S o?� T V/ , N, /s E(or)G) <br /> PROPER OWNER'S MAILING ADDRESS LOT# <br /> 0RK O 40r 2- bias c d <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Sf' Py✓1 ./>7N ss7/ S' /,/.� Yso-o7o7 <br /> II. TYPE OF BUILDING: (Check one) CITY NEAR ST ROAD <br /> State Owned O VILLAGE: <br /> ❑ Public �1 or 2 Fam.Dwelling—#of bedrooms PAR EL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) G�7f � � ' — <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 ❑ Res aurant/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. 054 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 S 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 31 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> S'Ste' <� 3 6!� .s 5'Feet y Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xiss Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tankor Holding Tank <br /> Lift Pump Tank/Siphon Chamber Irl] LH <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 Stamps) fdPJMPRSW No.: Business Phone Number: <br /> !f'Ao��_ Jly/�S�ro/rn 1 J3,GS <br /> Pluum�ber's Address(Street,City,State,Zip Code): <br /> r/; 0. d0k S1-i" S"r�i <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater ate IssuedIssuing nt Signa a( omps) <br /> Surcharge Fee) .-. <br /> pproved ❑ owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Ow er,Plumber <br />