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SANITARY PERMIT APPLICATION <br /> ^��xiR COUNTY <br /> ����� In accord with ILHR 83.05,Wis.Adm.Code / <br /> urK 4- <br /> -Attach <br /> ANITAR ERMIT a5 4 Lq <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ ( I q�j� GY 7 <br /> 8'%x 11 inches in size. <br /> Check if revisi to previous application <br /> —See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> t'i ,*,vr-oi �j�C' - '/4 IV '/a, S=)8' Tj r, N, R W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> --> So yo aid 3S 1 <br /> CITY,STATE 21PCODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 4 0. 11K4 <br /> II. TYPE OF BUILDING: Check one) CITY NEAREST ROA <br /> �7l' ( State Owned VILLAGE M.Tl¢A /��S 0 3S— <br /> ❑ Public IAJ 1 or t Fam. Dwelling,#of bedrooms PA EL TAX N3U_),?A <br /> MBER(b) <br /> III. BUILDING USE: (If building type is public,check all that apply) 7a0 '�/d <br /> oc <br /> 1 ElApt/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. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 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 C9 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 72.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> /� REQUIRED(sq.ft.) PROP/OSED(sq.ft.) (Gals/day/sq.tt.) (Min./inch) -�-ff ELEVATION <br /> 6100 S 7 gt0 �/ . o�Feet oZFeet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exner. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> ank or Holding Tank I I I MCI <br /> ift Pum ank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT a <br /> I,the undersigned,assume responsibility f r installation oft a onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): PI mber's ignat fre: No mps) MP/MPRSW No.: IBusiness Phone Number: <br /> N'?Cs 4; <br /> Plumber's Address(Street,City,State,Zip Code <br /> C Rd ter W <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groun)dwater Date ssue Issuin gent Signature(No Stamps) <br /> LApproved Surcharge Fee) <br /> ❑ Owner Given Initial �C� /), <br /> Adverse Determination �I O� vim✓/ 1. <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.OB/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />