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SANITARY PERMIT APPLICATION <br /> Leah i�arta COUNTY <br /> Leamill-linlillim In accord with ILHR 83.05,Wis.Adm. Code <br /> ���/1 <br /> STA �SIgITjt�F1)PERMIT <br /> ��-Attach complete plans(to the county copy only)for the system,on paper not less than II aOLL <br /> 8'%x 11 inches in size. F-1 <br /> Check if revision 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. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> �LSC G NU) '/4 <E '/4,S T Y0 , N, R /� E (o <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> CITY,STATES f ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> � NQJ/� is /1 <br /> If. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned VILLAGE <br /> ❑ Public ®1 or 2 Fam. Dwelling,#of bedrooms PAR LTAXN\UMBER( ) <br /> III. BUILDING USE: (If building 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 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPE <br /> OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> 1 <br /> A) 1. New 2. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System ystem 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 L�`ISeepage 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 DAY2.ABSORP.AREA 13.ABSORP.AREA 4. 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 /> it r/ <br /> 300 S S' Feet �f• 6 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding TankLH 1 Litt Pump Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Pu bar's Name(Print): Plum ure: Stamps), r 7 MP/MPRSW No.: Business Phone Number: <br /> .CD z /�� <br /> , 0�� X072 7/J- z l350 <br /> PI ber's Address(Street,City,State,Zip Code): <br /> /(0?/3 86", 3t �9�//�dr2 !.<J� 5zf Sof 8 3� <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(includes <br /> GrouFeendwater Date Issued Issuin g nt Si a r ( Sta pal <br /> ,Approved ❑ Owner Given Initial f(' /Q <br /> Adverse Determinati n ff--�� <br /> X.TONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />