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SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code & 74 Q <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATS I Y PERMIT# <br /> 8%x 11 inches in size. ❑ Check if revision to previousapplication <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 /> SIM 50KENSoIJ S � T39, N, R t E (o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# Bt <br /> 2(0005 Ve 1D . uC - c_ . �{ <br /> CITY,STATE 21P CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> LJ 1. <br /> sq S615 <br /> It. TYPE OF BUILDING: )one State Owned Check CITY f T NEAREST ROAD <br /> ( VILLAGE MCN <br /> PublicK1 or 2 Fam. Dwelling—#of bedrooms PARCEL XNUMBER(S) <br /> III. BUILDINGUSE: (If building type is public,check all that apply) � ((�-3�i4 —o4—aer <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 ❑ RestauranUBar/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.-EgReplacement 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 21Mound 30 ❑ Specify Type 41 ElHolding Tank <br /> 12 ❑ Seepage Trench 22 LJ 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 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 3o Q REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) p �E/L�EVATION <br /> 2-� L52- ' 2 �' 0 ' Feet l/0-.( Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New xistin Gallons Tanks oncrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holdino Tank �� <br /> Lift Pump Tank/Siphon Chamber jl sn Ii <br /> Vlll. 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 /> 1(4912V I� N �s �� <br /> Plu bar's Address(Street,City,State,Zip Code): <br /> Z?7 6 0 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee llncludesGFsunnowater Date IssuedIssuin g tSi at ur ( aSt pal <br /> Approved ❑ Owner Given Initial f� �j1 a 1 11 1�rJ <br /> Adverse Determination �1 i /( -/ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />