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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code co Nrr <br /> STATE SANT RY PERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than � �J 1� <br /> 834%11 IOCheS In size. Check if revision to 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 /> PRO1-PERRTY OWNER PROPERTY LOCATION �,p <br /> LADON A O� '% '/a, S 1-5 T/ /, N R 14 E (or)o <br /> PROPERTY OWNER'S MAILINU ADDRESS LOT# BLO K# <br /> 27-10 <br /> ITY,STATE ZIP CODEPHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> MN sso3� 0 CITY <br /> It. TYPE OF UILDING: (Check one) 1:1 State Owned VILLAGE: NEA EST ROAD <br /> ❑ Public 5&1or2Fam.Dwelling—{hof bedrooms PARCEL TAX NUMBER(b) <br /> III. BUILDING USE: (If building type is public,check all that apply) (a) �. f40 <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 ❑ Set vice Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Otter: Specify <br /> IV. TY��P77pE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. L/S!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 9 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 PEF7 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. FERC.RATE 6 SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Mir dinch) C� p ELEVATION <br /> 3eCo 7N 32 r ? ll/ 1 $ Feet 11. 3 Feet <br /> VII. TANK iC-A-PIACITY Site <br /> in allons Tolet #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App- <br /> s <br /> Tanks strutted <br /> Septic Tank or Holdinct Tank <br /> Lift Pump Tank/Siphon 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:(No SpsI MP/MPRSW No.: Business Phone Number: <br /> � o Z6 1 fab- 57 <br /> PI bar's Address(Street,City,State,Zip Code <br /> Z-I lGo 35 W11 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary P rmit Fee(Includes Groundwater a e ssue Issuing e t Signet r ( o pal <br /> Sur. rge Fee) �. '\ <br /> Approved F-1 Owner Given Initial -�' <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,0 ner,Plumber <br />