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11r,�I (Zlv, <br /> 7 SANITARY PERMIT APPLICATION <br /> t��ILllr�lln In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> r�rhG 0 7S8 <br /> STATE!SANITARY PERMI # <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 360670 <br /> 8%x 11 inches in size. ❑ Check if revision to previous application <br /> –See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> .'-J�cy, Jo '/4 '/4, So? T N, R /1' efvf) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# ✓� <br /> I S U I r-.d 4Y9. L 4L L!r1/9roa. <br /> CI ,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> R ,12- <br /> 11. TYPE OF B LOING' Check one CITY NEAR T ROAD <br /> ( ) El Owned 3 o TILLAGE.0 TOWN OF cJ <br /> ❑ Public *or 2 Fam. Dwelling-#of bedrooms— PARCEL TAX NUMBER(S) <br /> 111. BUILDING USE: (If building type is public,check all that apply) 46,;157- O.S-Soo <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 B if applicable) <br /> A) 1. El 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 /> 11Seepage Bed (41'44 21 El Mound 30 El SpecifyType 41 ❑ 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 12.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) / ELEVATION <br /> O 6413 8 Ino/ x 57 / 1 <br /> ' ` Feet I 1P7•4 Ill 4 Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in aallons Total #ofPrefab. Fiber- Exper. <br /> INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank <br /> Lift Pump Tank/Si Loo 1,104 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assr onsibility f r ihstallation of th nsite sewage system shown on the attached plans. <br /> Plumber's W! r b & EXCAVAT PI mbe ' gnature: o Stamps) rWAPRSW No.: Business Phone Number: <br /> N62281 Ias �7y <br /> Plumber's Address Code): <br /> (715)635-7482 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit (Includes <br /> Fee)water at/Issued <br /> 9 Issuing Agent ignature(No ps) <br /> proved ❑ Owner Given Initial jurch11 Y1 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />