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SANITARY PERMIT APPLICATION <br /> vi«ice In accord with ILHR 83.05,Wis.Adm.Code cou 4TY �y <br /> h e <br /> ST C SANT ARY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �� o��" vt <br /> 8'%x 11 inches in size. eck if evision 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 /> PROPERTY OWNER / PROPERTY LOCATION <br /> L ;hda of ,4 '/a f'/4,S.2 T,3 , N, R le E (or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCKY <br /> NZ i ke- e, /V A '7/� <br /> CITY,STT/ATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> /v <br /> eplfer J `1 9? 7/S �Cd- A <br /> If. TYPE OF BUILDING: (Check one) ❑State Owned VILLAGE NEAR ST ROAD / p <br /> A <br /> 4 0 <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms PARCEL TAX NUMB^E�R-1) <br /> 111. BUILDING USE: (If building type is public,check all that apply) - 33.,(d - O3 - 'Trfo <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 ❑ Ser 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 /> L1ck <br /> A) 1. New 2. Id 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 14. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> RE/gUII1RED(sq.ft.) PROPOSED(sq.ft.) (Gals/ /sq.ft.) (Mi nch) / SO EL�VATION <br /> C/ (� Feet �9 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New is Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> 1 El <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank /005 OOU PIJ Caq K <br /> Lift Pum Tank/Siphon Chamber Coo <br /> 00 / <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 /> a�` ce S, /JeATos1 1� � /y 6173 7/� 66 , a4F <br /> Plumber's Address(Street,City,Stale,Zip Code): <br /> 6S� P//<< .44 RJ d:/ ,6.rtee1Z/1 S e f3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved sanitary Pemit Fee(Includes Groundwater ate IssuedIssuin tS' natu e o mps) <br /> 1r,� Sun' Feel <br /> Approved ❑ Owner Given Initial . 1� ( r✓'�C�v k t)�—C,P <br /> Adverse Determination X41' IJ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,0 ner,Plumber <br />