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SANITARY PERMIT APPLICATION <br /> ELH) <br /> In accord with ILHR 83.05,Wis.Adm. Code co NTY (� <br /> i J�,C/12 <br /> STA SANITA,q1YPERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than � V <br /> 8'%x 11 inches in size. 1:1C eck It 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 /> Fiquc LK. LoD $ILL MILLER '/a /a, S Z T N, R 6 E (or(W) <br /> PROPERTY OWNER'S MAILING A DRESS LOT# �` ` BLOC # <br /> b q+,, ST d <br /> CITR,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> u So W - 5`tol6 7t5 %-3I <br /> It. TYPE OF BUILDING: (Check one) CITY NEAR ST ROAD <br /> State Owned VILLAGE �r 0 C L <br /> ❑ Public 1 or 2 Fam. Dwelling—#of bedrooms PARCEL TAX <br /> \NUUMMBER( )1 YY// <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo \��JJJ✓✓✓��� �^�r <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Out oor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Re taurant/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. ❑ Replacement 3.X 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 /> 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 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 PE97 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC. RATE 16. SYSTEM ELEV. 17. Fit <br /> AL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> JSb Z • Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of <br /> Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank �- <br /> Lift Pump 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 /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> lcHgRp a s 1 7/5' IS7 <br /> Plumber's Address(Street,City,State,Zip Code: <br /> 2'1 6 0 4u 3s UE67r6K 4WI. MS13 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Per it Fee(Includes Groundwater I Date Issued IssuingA i atur ( o to s) <br /> _Suro ) Fee) <br /> Approved ❑ owner Given Initial 1)�('TvC <br /> Adverse Determination U <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,0 ner,Plumber <br />