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0y) ctwp <br /> SANITARY PERMIT APPLICATION <br /> I <br /> O'ILFIR In accord with ILHR 83.05,Wis.Adm. Code COTY <br /> STA ESANIT{tRYPER�MIT I1C <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 6/Qb t JJJ d`IT \ ) <br /> 8%x11 inches in size. Check if revision to previous application <br /> -See reverse side for instructions for completing this application. STA rE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTYOWNER PROPERTY LOCATION <br /> —T-1 +w F6 v M ng Ya ni '/a, S 15 T ", N, 3 &W W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# 50 ,:14, So' EJF'11-600 BLOCK# <br /> I I 1 t,-) QkA, G' .L..1 oTt,) toot <br /> CITY,STATE ZIPCODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> tA)Aff6w u_ I QS7 1 5-ZOSO <br /> 1:1 CITY <br /> It. TYPE OF BUILDING: (Check one) 11 State Owned 13 VILLAGENEAR ST ROAD <br /> 12!!TOWN OF: o5kco't 'T' tZoRO <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms_Z_ PARC LTAX NUMBER( ) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) 04&- _I 1 1^ 1 _Hoo <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Res auranVBar/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) 1. ❑ New 2. 9 Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> Ell ❑ 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 ;K 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.AREA4. LOADING RATE 5. PER'. RATE 6. YSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.tt.) (Min./inch) ELEVATION <br /> 00 4$0 'E80 (,z- S3 95.3 Feet 97.31 Feet <br /> VII. TANK CAPACITY Site <br /> in alions Total #ofManufacturer's Name Prefab. Con- teel Fiber- plastic Exper. <br /> INFORMATION New xistin Gallons Tank's Concret strutted glass App. <br /> Tanks Tanks <br /> Septic Tank /4L0 <br /> Litt Pump Tank/ /000 I no <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,wo&nKresponsibility fo installation oft a onsite sewage system shown on the attached plans. <br /> Plumber's IRMS S EXCAVATION PImb Signature No Stamps) kIP/MPRSW No.: Business Phone Number: <br /> ISR 59, Box 4784 33 f3 <br /> Plumber's AtIp"MeWilly,SON04 Code): <br /> 15 7482 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> III��II... ❑ Disapproved SanitaryPQQrmit Fee Includes Groundwater ae IssuedIssuing a it Si natu- ( oSt ps) <br /> Ipp Approved ❑ Owner Given Initial <br /> ,/•/sCrc rge Fee) �^��_L+ ' <br /> �'\ Adverse Determination <br /> VV V <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Own r,Plumber <br />