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SANITARY PERMIT APPLICATION COUNTYau` <br /> TUILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE ANITARYRMIT#oZ0I&3q <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ ��v7(l�t.8'%x11inches insize. 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 /> eL oWS '% %,S 21 T N, R E (o W <br /> PROPERTY OWNq'SMAILI E1jj'jR Gc_?, Rv - LOT# I BLOCK# <br /> CITY,STATE 77 �� ��ZIIP CCOODEPHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> �B$1�R LJ t - SLt�13 e5/YZ V. b • l5 it) Eov't. L61 <br /> It. TYPE OF BUILDING: (Check one) CITY : N AREST ROAD <br /> Ipf State Owned VILLAGE O� EMNG�K Rn _ <br /> ❑ Public 01 or 2 Fam. Dwelliiof bedrooms 2 A <br /> III. BUILDING USE: (If building type is public,check all that apply) p2Cj- 43 D7 7- oq-c> <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 ❑ 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 2Replacement 3. ElReplacement 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 /> 11Seepage 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 12.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ff.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) / / ELEVATION <br /> C)n $0 pd 2 16.10 Feet Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New Istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks I Tanks structed <br /> Septic Tank or Holdina Tank <br /> Lift Pum Tank/Si hon 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(Print): Plumber's Signature: o mps) MP/MPRSW No.: Business Phone Number: <br /> �i-�1ARo H0?)()fJ3 4Z6 IS - PIIS <br /> lumber's Address(Street,City,State,Zip Code): <br /> Zllil w 35 W�B 5'TEIZ W I . S`48CI3 <br /> IX4 COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e ssu Issuing Age igna re( S mps) <br /> �A r' <br /> Approved ❑ Owner Given Initial urcharge Fes) <br /> ��� ccS <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/98) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />