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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTY <br /> STeA ESANITARY PER IT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than G s <br /> 8'%x 11 inches in size. p 7W _�j��7 <br /> Check if r ision to previous applibation <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 /> .J'j eC�e.J 1 �n A,/C'/4 A/Z4/'/4, S T � , N, R �E(or)*) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOC # <br /> CITY,STATE _ ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Cr <br /> ri7 <br /> 130ZArS ✓— SS337 !0/2 4vL- 39$' <br /> II. TYPE OF BUILDING: (Check one) LJState Owned Li CITY <br /> ❑ VILLAGE: NEAR 7ST ROAD <br /> W�55 lTq fA 3r` oGn 3S <br /> ❑ <br /> Public ,K1 or 2 Fam. Dwelling—#of bedrooms ARCEL AX NUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) V_3�__Kc)Oc / _61 <br /> 1 ElApt/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: (Cheeckckpppponly one in line A. Check line B if applicable) <br /> A) 1. El New 2.replacement 3. El Replacement of 4. El Reconnection of 5.❑ Repair of an <br /> System ystem 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 9seepage 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 Ej 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> fir/ "Feet /00`-0 Feet <br /> VII. TANK CAPACITY Site <br /> in alions Total #of Pretab. Fiber- Ex <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concret Con- feel Plastic Per. <br /> Tanks Tanks strutted glass App. <br /> Septic Tank orHoldin Tank _JG' $C WElX7L <br /> Lift Pu mp 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:IN Stamps MP/MPRSW No.: Business Phone Number: <br /> �OA7<}hp �R 'fZ �iS� 1�f9-3SO� <br /> Plumber's Address(Street,City,State,Zip Code): <br /> !G 7/ �i9r �u e Wi' S'ES 3c? <br /> IX. COUNTY/DEP TMENT USE ONLY <br /> DisapprovedI Sanitary P I Fee(Includes Groundwatera e ssue 1 Issuing Age Signet e o t mps) <br /> Approved ❑ Owner Given Initial Surrga Fee) <br /> Adverse Determination <br /> �l.J <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SB66398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division.Owne Plumber <br />