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) Ct)Y <br /> Ari- w SANITARY PERMIT APPLICATION <br /> %!� NTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STA E SANI RY PERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than �C��IC( <br /> 8%X 11 IDChe3 In 312e. Check if revision to previous application <br /> —See reverse side for Instructions for completing this application. STAFE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OW ER PROPERTY LOCATION <br /> CROW COuE. CgF_ '144. �%, S 1 T 41 , N, R 15 E (o <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# P <br /> CITY,STATE ZIPCODEPHONE NUMBER SUBDIVISION NAME OR CSMMMMUMER <br /> S . 4A ACI HIJ 55375 612 C—S/' I �1� �?O <br /> II. TYPE OF BUILDING: (Check one State Owned CITY VILLAGE NEAR ST ROAD <br /> S��s VK. <br /> ❑ Public ®1 or 2 Fam. Dwelling—#of bedrooms FAKCtL I AX NUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo LLII C, VV <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Res aurant/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. M 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 91 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 3O0 REO1/llluIR (sq.ft.) PROPOSED(sq.ft.) <br /> (Gal ay/sq.ft.) (Min./inch) ELEVATION <br /> yn��--E 3• e6 Feet qw. -3 Feet <br /> VII. TANK CAPACITY Site <br /> I <br /> all Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xistin Gallons Of Concrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank or HoldingTank ^� <br /> Lift Pum Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached pi ans. <br /> Plumber's Name(Print): Plumber's Signature:(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> fct{gRp ova<1�1s f� <br /> Plumbei s Address(Street,City,State,Zip Code): <br /> 27760 35 %v,16BS1r9 W). 9443 <br /> IX. COUNTY/DEPARTMENT USE ONL <br /> Ej Disapproved Sanitary Pe it Fee(Includes Groundwater ate Issued Issuin tS'g r IN tamps) <br /> t�Aroved Surc ge Fee) <br /> PP ❑ Owner Given ' C^n0 C�],., <br /> Adverse Determination �]� ( C7�� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Own r,Plumber <br />