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t R SANITARY PERMIT APPLICATION <br /> A COUNTY <br /> In accord with ILHR 83.05,Wis.Adm. Code <br /> 71C�heclk <br /> /�N_I Y PERMIT.#� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than r> PERMIT <br /> # <br /> 8%x 11 inches in size. if revision to previous application <br /> -See reverse side for instructions for completing this application. STA, E PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> CtAkkcy, SCIAU EMR '/4 /4, S 3q T N,JR 16 E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> CITY,STATE 21P CODE PHONE NUMBER <br /> 1 55092 (o/Z -WW7 PCK65 <br /> If. TYPE OF BUILDING: Check one CITY NEAR ST ROAD <br /> �}I ( > State Owned VILLAGE: <br /> 4PWy OFIs <br /> ❑ Public J—l^ 1 or 2 Fam. Dwelling-#of bedrooms, PAR EL I AX NUMBI,a. O ' t <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo l lJ <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 Bit applicable) <br /> A) 1.X 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 E7 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 16.!SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ' ELEVATION <br /> Son Zq Q <br /> 32 u3-Z- Feet 95.7 Feet <br /> CAPACITY VII. TANK CASite <br /> in all r_ Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xistin Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Se tic Tank or Holding Tank — I 1 <br /> Lift 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 /> Ir' RRD v iA/5 wluud 3�IZ(e 7/5- 366 /5 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 2.1766 HwX 3S WEgsTigg Wr. _5893 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issue Issuin g (Sign t re N tamps) <br /> Approved ❑ Owner Given Initial rcharge Fee) �. <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SB66398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety B Buildings Division,Ownler,Plumber <br />