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SANITARY PERMIT APPLICATION COUNTY7 L• HFR In accord with ILHR 83.05,Wis.Adm.Code <br /> STATESSS���NITARYRMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ E 4j <br /> �a� <br /> 8%x 11 inches in size. eck a revue o W 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 /> 17t�+rJ�S /�sc�4ris�c� 1 '/s �'/s,S # T `/o, N, R /I/ W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 7411 gl Sr 41 e <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> re4f SS s2 z- )7x-..V-u OSS V• )3 p.iq5 in C�- L, !9 <br /> II. TYPE OF BUILDI : (Check one) ❑State Owned Ll VILLAGE NEAREST ROAD <br /> o� �Gon LAKE !7Q. <br /> ❑ Public or 2 Fam. Dwelling-#of bedrooms— A IML NUM ER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) gO-411 C)q- <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home to ❑ 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 ® 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 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ff.) (Min./inch) ELEVATION <br /> 300 6 fVS` Feet �Fo. Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New istin Gallons Tanks oncret glass App. <br /> Tanks Tanks structed <br /> Septic Tankeo SLS / <br /> Lift Pump Tank/Sipon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Prinf�E�I^ L;A6 <br /> r's gnature:(No ps) VP/MPRSW No.: Business Phone Number: <br /> c VC & EXCA 3393 /715 63S-7tf2 <br /> Plumber's Address(Str tyB(r tP�� <br /> JJ1I YWV�I Sal <br /> al IX. ,COUNTY/DEPARTMENTZWCKY <br /> ❑ Disapproved rsanitsry Permit Fee (Includes,GroundwaterIssued Issuing/Ag ig lure Stamps) <br /> _ � t <br /> Approved ❑ Owner Given Initial rcharge Fee) <br /> /3•ll_yS-u) <br /> A v rmin i n <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/96) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />