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SANITARY PERMIT APPLICATION <br /> (7����+ In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STAT/E SANITA YPERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑l j&ir'ly� �CJ6q <br /> 8'%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 /> SERoMe '/a '/a, S �ZZ T N, R IG E (or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT#Is BLOCK# <br /> 3O Boa LA _Pa . <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> R SZ1$3o 5015D. 521Z_ <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned 59 VILLAGE S NEAREST ROAD /4h <br /> OWN OF <br /> El Public W1 Or 2 Fam. Dwelling-#of bedrooms— PAR EL TAX NUMBER( ) <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.Z 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 /> 11Seepage Bed 21 ElMound 30 ❑ Specify Type 41 ElHolding Tank <br /> 12 IFT 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. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) q J p ELEVATION <br /> 300 y 2 0 s I - Feet 1 `[ Feet <br /> CAPACITY <br /> VII. TANK in allons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank -- t2 <br /> Litt 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 Stamps) MP/MPRSW No.: Business Phone Number: �/ <br /> IcHgRo 0Vl</Nf t Tt ��z-6 7/5 01-Z ( <br /> P umber's Address(Street,City,State Zip Code): <br /> 2,'7164 -3-C, W605?ER W► $93 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> L] Disapproved Sanitary Permit Fee(Includes Groundwater Date IssuedIssuin g nits i natu IN Ste ps) <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial Q�LS <br /> Adverse Determination / 1 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SB66398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />