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SANITARY PERMIT APPLICATION <br /> DI�.HR TY <br /> In accord with ILHR 83.05,Wis.Adm.Code 9;4 <br /> STATE NITAR PERMIT# IC)S",I� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ / 105b� t 7`i <br /> 8'%x 11 inches in size. C�ec'k if revi ' n to 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. S -a <br /> PROPERTY OWNER PROPERTY LOCATION <br /> 4W4—.)v7.Y V .i er — t/4 — Y4, S /k/ T 57o, N, R /6 - W <br /> PROPERTY OWNER'S MAILI G ADDRESS I0b# 1 BLOCK# <br /> Xr`Z a.2P odi6L.af3- Lof/ <br /> CITY,STATE ZIP CODEPHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> _550-57iZ )3 94 622o 2— <br /> Lj <br /> If. TYPE OF BUILDING: Check one) CITY NEAREST ROAD <br /> ( State Owned VILLAGE. �KI�nO <br /> ❑ Public ®1 or 2 Fam. Dwelling—#of bedrooms 2- A <br /> 111. BUILDING USE: (If building type is public,check all that apply) <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 ❑ 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. ❑ 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 F-1in-Ground42 ❑ 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 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 /{IILQti•5 Feet z714 Feet <br /> CAPA ITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New isti Gallons Tanks Manufacturer's Name oncret �^- Steel glass Plastic App <br /> Tanks Tanks structed <br /> K 2 Z Ooo ! <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the site sewage system shown on the attached plans. <br /> Plu/mlber's Nate. Print): lu is Signature:( mps) WMPRSW No.: Business Phone Numbe <br /> 715- <br /> r: <br /> I t e�T �ZX u�a.� <br /> Plum is Address(S t,City,State,Zip Code): <br /> //CK 51 0.r 417,?,datone ' <br /> IX. COUNTY/DEPARTMENT USE ONL <br /> Disapproved Sanitary Permit Fee(includes Groundwater Date IssuedISSuin gent S' nature(N S ps) <br /> *PP El Owner Given Initial -1 I5� Surcharge Fee) ��� f� <br /> AdverseDetermination }r <br /> X. fdCONDITIONS rO AL/REAS/�S FOR <br /> AL: o <br /> �L6 (Lo(o N he/ /�I e R <br /> $ l <br /> 7� hl l R e <br /> %/{Sure �'of" � Ifa /�1a22al�o�i�7-' �ah�leCdve%5 -� (/est <br /> SBD-6398(formerly Plb-67)R.11/99) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />