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0�y) (_Z)7t1j. <br /> :... . .; <br /> SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code I_t� <br /> STA iTA Y PERMIT# l' <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ � � `11��l <br /> 8%x 11 Inches In size. heck if revision to previous application <br /> -See reverse side for instructions for completing this application. STATZ PLAN I.D.NUM'BE`R, I <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> 'R0 S T39 , N, E(or W <br /> PROPERTY OWNER'S MAILINGADDRESS <br /> x toss LOT# BLOC # <br /> 2 <br /> CITY,STATE I ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> FoL.K sT 2 4"As- <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned CITY NEAR ST ROAD <br /> VILLAGE ��o� 66 , �, A <br /> ❑ Public �1or2Fam. Dwelling-#ofbedrooms� AR LTAxNUMBER( ) <br /> 111. BUILDING USE: (It building type is public,check all that apply) -cj4- <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Out oor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Re taurant/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. ❑ New 2. X 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 K 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 15. PER1.RATE . SYSTEM ELEV. 7. ELEVATIONFADEREQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) FINAL G <br /> (M ./inch) <br /> 300Feet Q 3$Feet <br /> VII. TANK CAPACITY Prefab. Site Fiber- Exper. <br /> in allons Total #of Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> INFORMATION New .sting Gallons Tanks structed <br /> Tanks Tanks <br /> Septic Tank or Ho <br /> Litt Pum Tank/Si hon 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 Sta s) MP/MPRSW No.: Business Phone Number: <br /> 3q7_6 iS 86(o- &0 <br /> Pillintiber'S Address;(Street,C4. tate,Zip Cotle41 tl&5n5lZ W <br /> 2--71(ge) 111 <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> Issuin Wig ig ( Stamps) <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater ae ssue <br /> ,,,---,,,ccc/// Suroh;rge Fee) IR^-C <br /> pR Approvetl ❑ Owner Given Initial QU ) <br /> �` Adverse Determination <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division, caner,Plumber <br />