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� - � SANITARY PERMIT APPLICATION <br /> In accord with ILHR 63.05,Wis.Adm.Code OUNTY <br /> TAT NI RY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than a� d"� <br /> 8'%x 11 Inches In size. Check if revision to previ ud s application <br /> -See reverse side for instructions for completing this application. TATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER L <br /> OCATION <br /> FUS 5 �0 '/a, S I} T39 , R 16 E (o <br /> PROPERTY OWNER'S MAILING ADDRE S I BLOCK# <br /> 7-69 1 C14EL.M0 Ro - <br /> CI ,STATE ZIP CODE PHONE NUMBER tJAMEORCSJTMB� <br /> E6STa= WI - t? �� U id <br /> 11. TYPE OF BUILDING: (Check one) NE REST ROAD <br /> �NState Owned : WF <br /> ❑ Public I/VI 1 or 2 Fam. Dwelling--#of bedrooms f— PARCEL TAXNUMBER( ) <br /> III. 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 ❑ S Drvice Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ her: 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 /> 11Seepage Bed 21 ❑ Mound 30 El SpecifyType 41 El HoldingTank <br /> 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> V1. 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 /> Sop REOLIJjIREDD(sq.ft.) PRO�PjOSED(sq.ft.) Gals/day/sq.ft.) (Min./inch) a'1 O ELEVATION <br /> 121 -132- / 1`f• D Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Manufacturer's Con- Steel glass Plastic App <br /> Tanks Tanks structs <br /> Septic Tank or Holdina Tank OO <br /> Lift Pump Tank/Siphon Chamber Lj <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attache plans. <br /> Plumber's Name(Print): Plumber's Signature: No S mps) MP/MPRSW No.: Business Phone Number: <br /> c11RR0 kopxws 1 FL14� 3y2.4. 7/5 )&L- 451 <br /> Plumber's Address(Street,City,State,Zip Codej: <br /> Z'71160 9w, 35 tAl s Q WI- 3 <br /> IX. COUNTY/DEPARTMENT USE ONLY aaa <br /> E] Disapproved Sanitary Petit Fee includes Groundwater � ssue Issuin nt 'gnatu o mps) <br /> Approved ❑ Owner Given Initial Surcharge Fee) <br /> Adverse Determination U <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SB66398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division, ner,Plumber <br />