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1 Oil COMP <br /> SANITARY PERMIT APPLICATION <br /> ..■■ ■■.+ coin n <br /> In accord with ILHR 83.05,Wis.Adm. Code �c _ <br /> STA ISOAGN�ITA YPERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not lessthan l�O5'�J a 1 <br /> 834 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 - PROPERTY LOCATION <br /> '/4 /a, S 3 T39, N, � E (org@ <br /> PROPERTY OWNER'S MAILING ADDRESS LOT It BLOC # <br /> +` 5T <br /> CITY,STATE ZIPCODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> diu_E �3O(, (z $ z 5 Mil cf� 5 Ft AT $ 1 <br /> It. TYPE OF BUILDING: (Check one StCITY WEAN' NEAR S V'I ate Owned O VILLAGE C vV G <br /> ❑ ON <br /> Public �1 or 2 Fam. Dwelling—#of bedrooms PARCEL TWENAX NUMBER(5) <br /> 111. 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 ❑ Res auranUBar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Ser ice 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 �Z 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 12.ABSORP.AREA 3.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 /> 300 Qo S 100-12- Feet 03• 5- <br /> Feet <br /> VII. TANK CAPACITY Site <br /> In allons Total #of Prefab. Fiber- <br /> Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank om ��fOv�. <br /> Lift Pump Tank/Siphon Chamber Jtni <br /> Vill. 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:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> nls z6 /S 666- IS <br /> PI mber's Address(Street,City,State,Zip Co e). <br /> 27760 w 3s STE►z W1 - <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater ae ssue Issuing g nt Sign at re N tamps) <br /> Approved ❑ Owner Given Initial _S\'rcharge Fee) <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD6398(R.0893) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Ow at,Plumber <br />