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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY r <br /> STATE SAtN•IITT•A.t Y PERMIT: <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than F-1((-p�&� a�pf ID <br /> 8%X 11 Inches In size. Check if revision to previous application <br /> -See reverse side for instructions for completing this application. STATE TN 4p.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. -59 —d0-?-t-V <br /> PROPERTY OWNER LLTIYA <br /> ATION <br /> Df� l0 GE S ''/4, S 28 T37 , N, R 1$ E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS BLOCK# <br /> (o to+" Sr. r1 . - 3 <br /> CITY,STATE ZIP CODE PHONE NUMBER AME OR CSM NUMBER <br /> KPSOrJ �( • Sy 7/5 $b- Z} �- 173 <br /> If. TYPE OF BUILDING: (Check one) NEAREST ROAD <br /> State Owned <br /> >7 - L1c. Cb. Rte . <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms? MBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) Wq f s-M -03_qoo <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 IS 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 /> f <br /> 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 Ky 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 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROP .ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Feet Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or HoldingTank Z.doo � 1 -2-Doo ) <br /> Lift Pum 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): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Ie4liRo 3 Z� 'J15 8W6 yls7 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 2-7-7 ("o W -as wic-85 P, W1. -5`181 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing g nt Si net r ( o Sta pill <br /> Approved Sur�t�arge Fee) T <br /> ❑ OwnereDetermi al �j 'r-T hl) <br /> Adverse Determination —!Z �(-J <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />