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- � SANITARY PERMIT APPLICATION <br /> AA CO NTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> icr e # <br /> STj TE SANIT Y PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than &k?) 6 <br /> 8%x 11 Inches In size. Check if revision to previous application <br /> -See reverse side for instructions for completing this application. <br /> STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> eh f ieno)-j /r,A '% %, S%7¢/STYO , N R Iq E (cr <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLO K# <br /> IJ734 over <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> /e 1l//e_ &,74 s"S� 6/d2 CS/7 IS , `a i� 6_.L. <br /> TYPE OF 8 ILDING: (Check one) CITY NEA EST ROAD <br /> State Owned ❑ VILLAGESir TOWN OF: O AV <br /> ❑ Public X1 or 2 Fam. Dwelling-#k of bedrooms PAR EL TAX NUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> x- 9119 02 -7CO <br /> 1 El Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Ou door Recreational Facility <br /> 3 ElCampground 7 ElMerchandise: Sales/Repairs 11 ElRestaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Set vice Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Otter: 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. PER'.RATE 6 SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ccl� p•7 ELEVATION <br /> 300 7 J1 /jj4 Feet C1 7 G 0 Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New xistin Gallons Tanks oncrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank orHoldin Tank D � tJ �CYele <br /> Lift Pum Tank/Si hon Chamber /pC%C ^ C% Wi <br />