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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY (� <br /> STAUE ANI RY PERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than 'I <br /> 8'h 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 /> PROPERTYOWNER JPAE <br /> OCATION <br /> C ST,14L Mc, K66 W '/4, S T , N, R II E (or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT BLOCK# <br /> 2 I55 n. <br /> C TY,STATE ZIP CODE PHONE NUMBER �C <br /> 0 69V <br /> II. TYPE OF BUILDING: Check one �K�� NEAR STWAD <br /> ( > State owned djD <br /> ❑ Public g 1 or 2 Fam. Dwelling—#of bedroomsN/UMBER( ) '.)� <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> VVV <br /> 1 ElApApt/CondoCondo 3 c <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Out oor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Res auranttBar/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) 1New 2. ElReplacement 3. ❑ Replacement of 4. ElReconnection of 5.❑ Repair of an <br /> X-// ``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.P�Dvlound 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 72.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. YSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 3 S 1.7— ?'8 Feet 00-0Feet <br /> VII. TANK CAPACITY Site <br /> in gallops Total Of Manufacturer's Name Prefab. Con- feel Fiber- plastic Exper. <br /> INFORMATION New istin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank W (7 <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached pi ins. <br /> Plumber's Name(Print): Plumber's Signature:(No tamps) MP/MPRSW No.: Business Phone Number: <br /> ic 3;4n �S U- IIS <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 60WV 3S WI <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued ssuin e it Sign t re( tamps) <br /> }r. umi� <br /> Approved ❑ Sarge Fee) <br /> Owner Given Initial tt I <br /> Adverse Determination --Cf O <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Own r,Plumber <br />