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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code cou Tv <br /> STA ESANI RYPERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than a R 16 <br /> 6'/z x 11 Inches In size. heck 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 PROPERTY LOCATION <br /> $oH100f /s '/., S ZS T , N, E (or W <br /> PROP RTY OW ER'S MAILING ADDRESS LOT# BLOC # <br /> Hwy 35 A. q1I 10 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> pn NR \41 54S3o 51< ACR - <br /> II. TYPE OF BUILDING: (Check one) CITY : � 1 NEAREST ROAD <br /> I�pp(( State Owned 4OWN VILLAGE: an N G flK SK D, <br /> ❑ Public NO or 2 Fam. Dwelling—#of bedrooms-7= PAR EL IAANUUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) Ql�.�'00 <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Out oor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ElRes aurant/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. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1.;4 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 1 2,ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.)3 PROPOSED(sq.tt.) (Gals/day/sq.ft.) (Min./incl ELEVATION 0 0 i f 7_41 /Z • // 74.e,4 1 7. 0 Feet -S Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- reel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or HoldingTank <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(N tamps) MP/MPRSW No.: Business Phone Number: <br /> Ict1AR0 OPK/r1Sd 3`f Z6 lis <br /> Plumber's Address(Street,City,State,Zip Code): <br /> a gw4j 35 gBSTm2 wl• sgg(i3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary rmit Fee(includes Groundwater ate IssuedIssuin l�ign u (� Stamps) <br /> Approved F-1Owner Given Initial l�O rge Fee) <br /> JD <br /> Adverse Determination <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 />