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SANITARY PERMIT APPLICATION <br /> r '� F1 In accord with ILHR 83.05,Wis.Adm.Code COU <br /> n <br /> to the county co STA SCAN`D`f Y PERMIT# <br /> –Attach complete plans <br /> ( ty py only)for the system,on paper not less than (6�d1� ��'� <br /> 8%x 11 inches in size. �i 1 <br /> het if re ision 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. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> ESN £L..KIIIS '% Ya, S J"X Ty ( , N, I E (OKOP <br /> PR 'Y O'NER'S MAILING ADDRESS LOT# �,� BLOCK# I� <br /> CITY,STAL,_IfATEZIP 030 PHONE NUMBER tl' Z SU IVI Q�N NAMI�QR CS /J�MBEF.6 t J <br /> II. TYPE OF UILDING: (Check one) e Dw CITY k NEAR ST ROAy <br /> ❑ State Owned O VILLAGEFt TOWN OF <br /> ElPublic X1 or 2 Fam. Dwelling–#of bedrooms 3 PARCEL TAX NUMBER(b) <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 ❑ Res aurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Ser ice 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. N 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 ❑ Specify Type 41 ElHolding 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 91 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> i Lr , REQUIRED(sq.f.) PROPOSED(sq.f.) (Gals/day/sq. <br /> ls/day/sq.f.) (Min./inch) ELEVATION <br /> —/ 693 O S'Q Feet e •3 <br /> Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank f— I POO <br /> Lift Pump Tank/Siphon Chamber FO—T F1 I F1 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached pi ans. <br /> Plumber's Name(Print): Plumber's Signature: Stamps) MP/MPRSW No.: Business Phone Number <br /> It-flARfl M4 IlM� , u <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 7-7760 3S (nJ�$S�E wl- ,58 3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date IssuedIssui nt Sign ur ( tamps) <br /> y.L Surch@rge Fee) <br /> pproved ❑ Owner Given Initial L' ' `�-_`5u <br /> Adverse Determination -9 1 (—j V <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SB66398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Own r,Plumber <br />