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or <br /> SANITARY PERMIT APPLICATION 'couNrY c <br /> ^■■ ■■■+ <br /> ►�+��-�■■� In accord with ILHR 83.05,Wis.Adm.Code <br /> ST TE SANITARY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than a �� <br /> 8'%x 11 inches in size. <br /> ❑ Check if revision to revious application <br /> -See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. tL/ <br /> PROPERTY OWNER PROPERTY LOCATION / <br /> —D".. ¢.u6o-w (IvSt5►�'/a, S 13 T 35 , N, R 1 f f=)W J <br /> PROPERTY FNER'S MAILING ADDRESS LOT# BLOCK# <br /> t'o . o x 3-Ab E <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMB <br /> Lk)h;34,e /A• 01 1 *1.1 Car 119 <br /> a <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned O I!LTOWN F' (meq <br /> ❑ Public &�1or2Fam. Dwelling—#ofbedrooms— PARCEL TAXNUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) �^ 3113—®5--/Cc <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 ❑ RestauranVBar/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. RNew 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 9 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 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 /> 9-/(pFeet >94. / Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility fol install tion oft onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print):M & K PIber' gnature: o Stamps) NSlMPRSW No.: Business Phone Number: <br /> SEPTIC & EXCAVATI 3 3 <br /> N111229 Cai-OF I*-n MA <br /> Plumber's Addr p ode): <br /> 715 635-7482 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> �7( ❑ Disapproved Sani ary Pet Fee(includes Groundwater a e ue Issu' g Age Signatur Po Stamps) i <br /> Approved ❑ Owner Given Initial Surcharge Fee) <br /> �( Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(8.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />