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SANITARY PERMIT APPLICATION -_a :;SZErr.
<br /> ,n accord with ILHR 83.05,Wis.Adrn Cooe - --
<br /> .. -t,.;l ete plans'to :he county copy only)for the system, on paper not less i County..-) ^ �- -?
<br /> .^c`3es; size '.�t i~+ i Flt " --
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<br /> ?-;=Sib for s'?st'uCtions for completing this application State Saar itt7ar errnit Number (--,1-717;
<br /> ()51-75q
<br /> _r u-a cv'de may be Jced by other government agency programs 0 Check ii revs n io previous epDi>ce
<br /> _ _ :.'D4"'(m)i State Plan I.D.Number
<br /> APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
<br /> . .,�,,e, ^tame Property Location
<br /> /f�,,t #S �L%: fr...r o A- ''� 11/. S E 1/4,S / T 3 7 , N, R / ?(or W
<br /> oi.
<br /> yr-•er .Ma.ii^."Address Lot Number I Block Number
<br /> t ' Y p `y7`4 Lame N.
<br /> IZip Code I Phon Number Subdivision Name or CSM Number
<br /> r,,:, , ;r✓,u i •5"Y3y (6/) ) 8S.2.s b - -_j
<br /> TYPE •F BUILDING: (check one) 0 State Owned .qty Nearest Road
<br /> .'
<br /> ' ut):�t 1 or 2 Family Dwelling- No.of bedrooms 3 3 Town OF.4sac , dieU.::.
<br /> hi%P `�r"`'f '--u' 9'`i
<br /> ! BUILDING USE: (if builoing type is public,check ail tnat apply) Parcel Tax Number(s) o 3 Y /s%,/ . o ; 6/ 4)
<br /> 4.Udr:^gent. Condo
<br /> fir'— i S'c7/ c; Z.50‘:
<br /> '7asse'r'o!y Hal! 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
<br /> 3 Camoround 7 ❑ Merchandise: Sales/Repairs 11 0 Restaurant/Bar/Dining
<br /> _?^Bron'. r School 8 0 Mobile Home Park 12 7 Service Station/Car Wash
<br /> -i .e; tv'otei 9 [ Office/Factory 13 ❑ Other: spec.,,,,
<br /> i' TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
<br /> .New 2 Replacement 3. ❑ Replacement of 4_ C Reconnection of S, r Repair of an
<br /> Sysiem System Tank Only Existing System Existin fa System
<br /> .a Sanitary Permit was previously issued. Permit Number Date Issued
<br /> ,` TYPE OF SYSTEM: (Check only one)
<br /> _ssu r.zed Dlstrlbutrorr Pressurized Distribution Experimental Other
<br /> , Ser?^ ya Bea 21 ❑Mound 30❑Specify Type 41 p Hoiding Tank
<br /> _ Stodge Trench 22❑In-Ground Pressure 42❑Pit Privy
<br /> _ Seg ,.ii,,;e Pit 43❑Vault Privy
<br /> •;'l ABSORPTION SYSTEM INFORMATION:
<br /> :II n Pe Day 2 Absorp. Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 16. System Elev. 7. Final Grade
<br /> Rersuired (sq.ft.) ProposedAq.ft.) (Gals/day/sq.ft.) (Min./inch) Q Elevation
<br /> 4/5-^`�' o /8x0'0=/D0 • $ J 1 L / Feet, /02,`c"Feet
<br /> Al. TANK 1 Capacity `.
<br /> in gal{ons Total I #of Prefab [ sive 1 i y,ber. ex e
<br /> INFORMATION } Gallons ; Tanks Manufacturer's Name Concrete Con- Steel I dead Plastic Agp
<br /> New Existing �sruaedl
<br /> ___ I T{ant
<br /> ..A ur*oicing Tank 1 !YI/k ss��" i Tanks I'0V 0 i t 40 '''N-1 QJ 0 ❑ I :_! -i ❑ ❑
<br /> „-rk :',prion Chamber 1 WQ) glD 4') / // l 0 I 0 ❑ 1 L i ❑ i ❑
<br /> ,.}Ill RESPONSIBILITY STATEMENT
<br /> -oes:gned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
<br /> %a—L.,. rint) , PI mber's Sig'bture:i.No Sta -84 ' ,,MPRSW No.: Business Phone Number.
<br /> -,,, s duress:Street,City,State,Ztp Code).
<br /> •X. COUNTY/ DEPARTMENT USE ONLY
<br /> Disapproved I Sanitary Permit Fee {indudesur0undwater Date issued Issuing Agent$,nature'No Ste^os'
<br /> 1�,'-SF1{`Pr.;tt^ r•-? '* SurchargeF eel
<br /> "Owner Given Initial )) -7-;)-q-5- �/�
<br /> Adverse Determination (5C` ��il `l ,—.__
<br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
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<br /> _ ____. r)'.R:zhi,!(i' ngu,a:to Cool.ty nor o+r•y Te: S,'rty 8 Ru41,L,,,,,nic.,iun.f iwurr P:umi.ar
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