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SANITA�Y PERMIT APPLICATION <br /> LHR In accordw ith ILHR 83.05,Wis.Adm. Code COUN <br /> t(TY N ETT <br /> STATE ANITA PERMIT#�jr-g�,L�g9 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than v�7( <br /> 81/2x 11 inches in size. F-1 ec�fev' on to previous application <br /> wee reverse side for instructions for completing this application. L/ / STATE�P}^N I.D.NUM R� <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. 6Y 5 <br /> PROP RTYOWNER n PROPERTY LOCATION p� <br /> I' I I e—r- '/4 Ya, S T W, N, R Iq E (or)NY/ <br /> PROPERTY OWNERS MAILING ADDRESS LOT# BLOCK <br /> 135" e7H „E.I <br /> CI7/y�,ST aATE IA(! ) 21P CODE PHONE NUMBER SUBDIVISION NAME OR CSM"NUMBER <br /> If. TYPE OF BUILDING: (Check one) ❑State OWned CIN NEAREST ROAD _ <br /> VILLAGE: �� Co Rd. <br /> QPublic 1:11 or2Fam. Dwelling—#ofbedrooms— u R a�—y�a6-OI-510 <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 W 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. ❑ 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 /> 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 PER DAY 12.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE '_ PE <br /> . PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (MiRrSinch) ELEVATION <br /> Z `7 a �� S Feet 10Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallona Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdinct Tank <br /> Lift Pump Tank/Siphon Chamber - Oo <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for in allati eonsite sewage athe attached plans. <br /> Plumber's Name(Print): r' Si nature: o S ps) MP/AIIRSW No.: Business Phone Number: <br /> PI bar's Address(Street,City,S te, i C de . <br /> p o , 161 K4-8 <br /> OUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater e e ue Issuing A nt Si natu a No Stamps) <br /> surcharge Fee) <br /> Approved ❑ Owner Given Initial �OS ^� j [y <br /> Adverse Determin ' n �J Y <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />