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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couNTv <br /> STATE SANITARY PERMIT# <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than � 9/ 7-7 <br /> 8'h x 11 inches 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 /> PROPERTY OWNER PROPERTY LOCATION <br /> tLLXA '/4 /4, S it T3A , N, R I E (o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> a to-7141 fkRrar1 LA RE .1-.1 ?-dWce-L_$ <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> ooneX uJ. 5 o1 11,155 <br /> It. TYPE OF BUILDING: (Check one) CITY71 �OWW <br /> NEAREST ROAD nUG <br /> II.���II ❑ State Owned 0 VILLAGE: K <br /> ❑ Public X1 or 2 Fam.Dwelling-#of bedrooms>3- PARCEL TAX NUMBER(5) <br /> III. BUILDING USE: (If building type is public,check all that apply) <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 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 ® 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 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 9a sfoys ELEVATION <br /> S4,50 1 6s/43 `./B njai h Feet 17&.5' Feet <br /> VII. TANK CAPACITY Site <br /> in al Ions Total #Of Prefab. Fiber- Exper. <br /> INFORMATION New is <br /> Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank qp0 Opo <br /> Lift Pum Tank/Siphon Chamber 'a-�— <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,asf"rV6ponsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's "8[ EXCAVATI er's Signature:( Stamps) MR/MPRSW No.: Business Phone Number: <br /> N6228 Coun Line Rdsawl . 3393 <br /> Plumber's Address ip Code): <br /> UfA COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Is Ing enl Signatu (No Stamps) <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(1108/93) DISTRIBUTION: Original to County,One Copy TO:Safety&Buildings Division,Owner,Plumber <br />