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` 2 SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis. Adm. Code co ry <br /> utne77` <br /> STATE SANITA Y PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than d�,f�'�� d S <br /> if- <br /> 8%x 11 Inches In size. 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 / J PROPERTY LOCATION171�di <br /> eA / �'c d 4JCt � '/4 '%' S TT T p, N, R/ E (or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT#� BLOCK#� <br /> CV <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUM ER <br /> /e S!- Gi C � 15 • gin 6. Z. g <br /> . TYPE OF B LD1NG: Check one CITY NEAREST ROAD <br /> I <br /> ( ) El Owned O VILLAGE sof 0 #_ <br /> ! �� <br /> �} <br /> ❑ Public ,I�1 or 2 Fam. Dwelling-#of bedrooms PARCELT NUMBER(S) <br /> oX 41)7- oa-loo <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. TYPPE1^OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. �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 ❑ 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 2.ABSORP.AREA 3.ABSORP.AREA 4, LOADING RATE 5. PER'.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.tt.) (Min./inch) `'/ ELEVATION <br /> 3 / 7 N/� 9�o SIC Feet 98-U oFeet <br /> VII. TANK CAPACITY Site <br /> I n allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xistin Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank .� ZOO Ue/J Conpe <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,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 /> a /a t e j, eh fo , � /'9PG 9 7 3 j <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing ge Signatur No Stamp ) <br /> Approved ❑ Owner Given InitialII �fes(Su[charge Fee) <br /> Adverse Determination 1J� 17- <br /> X. <br /> -X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />