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C✓t1 wtl �', <br /> �- SANITARY PERMIT APPLICATION couN <br /> :.. <br /> In accord with'LHR 83.05,Wis.Adm.Code <br /> STAT SANIT YPERMf# 1�� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than c eck�6sion to previous application <br /> 8'%x 11 inches in size. <br /> ER <br /> —See reverse side for instructions for completing this application. STAT PLAN I.DD..;UMBB <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. ER <br /> UU// <br /> PROPERTY OWNER PRO'PE1RTY LOCATION // <br /> : �f LL►�IRI, c� W'/< CJE '/a,S �b T N. �$ E (or <br /> LOT# <br /> PROPERTY OWNER'S MAILING ADDDRESS D <br /> BLOCK <br /> 1 1$a8 5Ti4YE R <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> CITY <br /> It. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE:IN OF <br /> A <br /> ❑ Public 01 or 2 Fam.Dwelling—#of bedrooms PARCEL TAX NUMB R(�:aNURE3HTROAD_ <br /> 111. BUILDING USE: (If building type is public,check all that apply) LL4-- <br /> 1 ❑ Apt/Condo 10 ❑ Out oor Recreational Facility <br /> 2 AssemblyHall 6 ❑ Medical Facility/Nursing Home 11 El Res ur Recreational <br /> /Dining <br /> 3 El Campground 7 El merchandise: Sales/Repairs 12 ElService Station/Car Wash <br /> 4 El Church/School 9 El cEl te/Factole ry ark 13 ElOth r: Specify <br /> 5 ❑ Hotel/Motel <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> r of an <br /> A) 1 1A New 2. ❑ Replacement 3. El Rank Onacely <br /> of 4. Existing System Reconnection of5 ❑ Existing System <br /> System System y <br /> B) ❑ A Sanitary Permit was previously issued. Permit# <br /> Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental <br /> Other <br /> 11 ❑ Seepage Bed <br /> 21 R Mound 30 El Specify Type 41 El Holding Tank <br /> 12 ❑ Seepage Trench 22 In-Ground 42 ❑ Pit Privy43 ❑ Vault Privy <br /> 13 ❑ Seepage Pit Pressure <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: FINAL <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC. RATE 6 SYSTEM ELEV. 7. ELEVATION GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Galla/day/sq.ft.) (Min./inch) �. ''� Feet Q 1 Feet <br /> 300 (o0 600IS <br /> CAPACITY Prefab. Site Fiber- Exper. <br /> VII. TANK in allons Total #of Manufacturer's Name Con- Steel lass Plastic App <br /> INFORMATION New xistin Gallons Tanks oncrete structed g <br /> Tanks Tanks <br /> Se tic Tankor Holdin Tank 00 �r1 <br /> Litt Pum Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> MP/MPRSW No.: Business Phone Number: <br /> Plumber's Name(Print): Plumber's Signature:(No mps) ��� �'`� <br /> ICHAX0 DPJK1t45 w�Md J <br /> Plumber's Address(Street,City,Sttate ZID d , `WgBsr6jz WI - 5493�W 11 rj. 2 <br /> t7 9 <br /> IX. COUNTY/DEPARTMENT USE OWL J ssuin <br /> Disapproved Sanitary Per(nIt Fee(IRates issued <br /> 9 9 gnatu S Ps) <br /> ncludes Groundwater a <br /> ate(/ surcharge Fee) ^ <br /> Approved El owner Given Initial /•l <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD66398(R.08/93) DISTRIBUTION: Original to County,One Copy TO:Safety&Buildings Division, wner,Plumber <br />