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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code oouN <br /> STAT SA_ PERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than B(�t <br /> 8'%x11inches insize. ❑ Ceckifrevi onto 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 /> f( ssE, '/4 '/4, S Z.3 T N, R 6r E (Or W <br /> PROPER OWNER'S MAILING ADDRESS LOT# BLOCKif <br /> ZDI Z UIFFEENDALL 9 <br /> CITY,STATE I ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CS MB R <br /> AR a MN . o2 12 60•b%Z � V v <br /> II. TYPE OF BUILDING: (Check one) Li CITY NEARE T ROAD <br /> ❑ State Owned VILLAGES o E D <br /> ❑ Public �1 or 2 Fam.Dwelling–#of bedrooms� AR EL TAX NUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) �1- <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 ❑ Rests urant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Othe : 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 Fj 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC. RATE 6. E YSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> SCO 9 Z`i 32 7 1 — Q ' 3 Feet 7•9 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- feel glass Plastic App <br /> Tanks Tanks ✓✓ strutted <br /> Septic Tank or HoldingTank G <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 pl ns. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> t Ml Z6 ' /S $bb- �IS7 <br /> PI bar's Address( reef,City,State,Zip Codef. <br /> 2'1 1 bo Nl,435 1JE65[�R W1 . 54$53 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater <br /> water a—e1Issued(!— Issui <br /> e s) <br /> suupprg.Fee) <br /> �Approved Downer Given Initial iict <br /> Adverse Determination '�� <br /> \ / J <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Own r,Plumber <br />