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�„ ,r, SANITARY PERMIT APPLICATION <br /> r_ TY <br /> allil a In accord with ILHR 83.05,Wis.Adm. Code COU 3 <br /> STATESANIT YPERMIT�#� ,��-p <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than Cly n�� �dR(f 0 <br /> 8'f x 11 inches in size. ❑ Check if revi111ision 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 /> Ci_W4K k.)EHVeP, Sk '/4r1ev4, S 19 T 40, N, R 14 W <br /> PROPERTY OWNER'S MAILING ADDR SS LOT# BLOCK# <br /> 303o Ca 'AUT C-�'T ,� <br /> CITU,$TATE ZIP E PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> �;tE 548°f3 b35 9 <br /> II. TYPE OF BUILDING: (Check one) CITY NEARS T ROAD <br /> �� State VILLAGE SCO I <br /> 57' the rfIN 4 . s. t me_ <br /> Public 1 Or 2 Fam. Dwelli g-#of bedrooms_ PARCELTAXNUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ ApVCondo V lJ <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranUBar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 19 Other: Specify o <br /> IV. TYPE OF PERMIT: (Check <br /> only one in line A. Check line B if applicable) <br /> A) 1. ElNew 2. N 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.ft.) (Min./inch) ELEVATION <br /> 300 .547rl . 7 1W01 h. 9V.6 Feet F4,4 Feet <br /> VII. TANK CAPACITY Site <br /> in 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 O /O00 <br /> Lift Pum Tank/ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of thp onsite sewage system shown on the attached plans. <br /> Business Phone Number: <br /> Plumber's Name(Print): PI"b 's Signature: o Stamps) MPfMPRSW No.: <br /> L 7i`__ r.t50'✓t <br /> Q 3353 71 s G 3 S 75<�' <br /> Plumb 's Address(Sbbet,City,State,Zip Code <br /> � <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Incudes Groundwater a essue Issuin A nt Signa a(No S ps) <br /> Approved ❑ Owner Given Initial ,yµ L �\ Su rpe Fee) n <br /> Adverse Determination _$ `�-'O �11 <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 />