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Cm( <br /> SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code cou TY <br /> STA SANIRY PEF�MIT# ' <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than LL((,�J�� "_IM 7( <br /> 8'%x 11 Inches In size. neck if revision to previous application <br /> -See reverse side for Instructions for completing this application. STA E PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PRO�j ERTYOWNER PROPERTY LOCATION <br /> l� C, T I}( �G( /1)01/4 5c 1/4, S � T N, R/6 E (or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOC # <br /> q� c . � - 9 <br /> C TY,S ATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> lt?�uS-V_Vo Q/A-c .6*-� ,rr-0 CITY <br /> i9 f^e <br /> II. TYPE6F BUILDING: (Check one) 1:1 State Owned 0 VILLAGE NEAR ST ROAD <br /> ❑ Public V'1 or 2 Fam. Dwelling-#of bedrooms� PARCELTAx NUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) Ca� <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Out oor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Res aurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ SerN ice Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Oth r: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. 54-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 13.ABSORP.AREA 14. LOADING RATE 5. PERC. RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ^ �FELEVATION <br /> C f� -121-27 '/o3 2 i y �d Feet / 7' 6 Feet <br /> VII. TANK CAPACITY Site <br /> ingallon Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdin Tank 4 OvO O ,j /fd✓ <br /> Lift Pum Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached p ans. <br /> Plumber's Name(Prin): Plumber's Signature:(No S ps) .MFYMPRSW No.: Business Phone Number: <br /> Plum Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Prr11��// ❑ Disapproved Sanitary Per t Fee(�Inpclructln�eslgG�rFee) ter a e ,a Issuing nt Sign e N tamps) <br /> Approved ❑ Owner Given Initial ( /� Fee) ^IP <br /> ::��11 Adverse Determination I <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To;Safety&Buildings Division,Ow at,Plumber <br />