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0� 0`00000000111 1UAR SANITARY PERMIT APPLICATION COU <br /> Emmonsv_ In accord with ILHR 83.05,Wis.Adm.Code �U <br /> STATE SANITARY PERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than 13�Z_� �� ��� <br /> 8t%x 11 Inches In size. ❑ Check if revision to previous aic�tion <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 PROP�RTY LOCATION <br /> L-'/45U)I/t, S 3 T3?, N, R -He W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> a wootl CWeK 26,4 <br /> CITY,STATE I ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> IL TYPE OF BUILDING: (Check one El <br /> CITY NEAREST ROAD Coact❑State Owned VILLAGE :-7 11 40wij Q� n f P� 00 d C�� F.Q¢d <br /> ❑ Public IN 1 or 2 Fam. Dwelling-#of bedrooms EL TAX NUMBER(S) <br /> 1 11 <br /> 111. BUILDING USE: (If building type is public,check all that apply) — Z—j — O Z- <br /> 1 ❑ ApVCondo <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. V Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> 8) ❑ 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 N 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.AREA3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/ q.ft.) (min./inch) ELEVATION <br /> SO 5- 7 �i .o^ / Feet `y Feet <br /> VII. TANK FNRI <br /> PACITY Site <br /> allonsTotal #of Prefab. Fiber- Exper. <br /> INFORMATION w istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass PlasticAppks Tanks strutted <br /> Se tic Ta or Holdin Tank 'A 1er [Q$PY C <br /> Lift Pump Tank/Siphon 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: Plu ber's 'gnature: No mps) MP/MPRSW No.: Business Phone Number: <br /> hlP 5-7 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> s C l Qlos�� ( c1 cs S�Bi <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved I Sanitary Permit Fee(Includes Groundwa[er a e ssue Iss ng gent Sign (No Stamps) <br /> Surcharge Feel <br /> pproved ❑ Owner Given Initial O _1 C_z G__(� <br /> Adverse Determination �� CJ s l <br /> CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb67)(R.11/86) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />