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I &-n <br /> SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code co N <br /> STA ricaSRYPERgI qqt _ <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than C����rYY <br /> 8%X 11 Inches In size. Check if revision to previous application <br /> —See reverse side for instructions for completing this application. __9T_ATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PR PERTY LOCATION <br /> 6y 5 'd5� '/a, S ; �? T,3N, R16 E (or) <br /> PROPERTY OWNER'S MAILING ADDRESS L # _ BLOC # <br /> ��fr �� s L k J <br /> CITY,STATEZIP CODE PHONE NUMBER SUBDIVISION NAME 08-CSM NUMBER <br /> (( <br /> II. TYPE OF BUILDING: (Check one CITY NEA EST ROAD <br /> ❑ State Owned ❑ VILLAGE M e eNwn-) 5 :5— <br /> ❑ Public 0 or 2 Fam. Dwelling—#of bedrooms PAR LTAX NUMBLR((b) <br /> III. BUILDING USE: (If building type is public,check all that apply) Q �- t1X— �_ain <br /> 1 ElApVCondo u <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Re tauranVBar/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 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERI.RATE 6 SYSTEM ELEV. 7. FINAL GRADE <br /> r REQUIRED(sq.ft.) PROPOSED(sq.tt.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> � A j 00 75' 761/19 Feet 9, —2 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Nam e Concrete Con- Steel glass Plastic App. <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdina Tank 3001 .���G ��O✓ <br /> Lift Pum Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached 1 Plans. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> .?�6 <br /> Plumber's Address(Street,City,State,Zip Code): c�o <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee (Includes Groundwstar ae Issued issuing nt Sit Mare oStamps) <br /> 1-r S arge Fee) <br /> Approved ❑ owner Given Initial µ Ip <br /> Adverse Determin tion •�-P t--' <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,0 ner,Plumber <br />