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1.7- 11, <br /> SANITARY PERMIT APPLICATION <br /> COUNTY <br /> In accord with ILHR 83.05,Wis.Adm. Code -� <br /> Yet t-T� <br /> STATE SANITARY MIT <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ T�RY <br /> 8th x 11 Inches In size. k if revision 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 OWNERPROPERTY LOCATION _ <br /> EY7i �/ y �rri ) ' i''/aS Ft/a,S -3 t T Q, N, R W <br /> PROPER OWNER'S MAILING ADDRESS LOT# BLOCK <br /> 7j e <br /> CITY,STATE—, ZIPODE PHONE NUMBERSUBDIVISION NAME OR CSM NUMBER <br /> II. TYPE OF BUILDING: (Check one) ❑State Owned VILLAGE:J NEAREST ROAD <br /> l�pl 4.c Ks�,-, ,.Q4 T=Qqt1 <br /> ❑ Public Lg11 or Fam. Dwelling-#of bedroorri 4RCELTAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) 619— L(a 13 — 06 4/5o <br /> 1 ❑ ApUCondo <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 /> 11Seepage Bed 21 ElMound 30 ElSpecify Type 41 ❑ Holding Tank <br /> 12 N 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 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 2 REO /IRED(sq.ft.) PROPOS�EDry(sq.ft.) (Gals/day/sq.ft.) (Min./inch) q gELEVATION <br /> 3 o l C �_o r r3-3- 3 J 6' Feet L 16 Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrate Con- Steel glass Plastic App <br /> Tans Tanks strutted <br /> Se <br /> it or Holdin Tank 1 <br /> Lift Pump Tank/Si hon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Prin): PI ber's Si (N MPIMPRSW No.: Business Phone Number: <br /> L Kae f' �'> iMP S7 7t E <br /> Plumber's Address(Street, ity,S te,Zip e): <br /> 7 CCf. ; <br /> COUNTY/DEPARTMENT UBE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e ssue Issuing Agent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial MSurcharge Fee) ^_� , .,✓ly.�,/& <br /> Adv in tin - ���' w –� lJ `7" <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />