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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTY <br /> CCT SANITA YPERMIT <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than Ca <br /> %I- <br /> 8%x11 Inches In size. in, heck If rev .to previous application <br /> -See reverse side for instructions for Completing this application. STA E PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> FF-1966 '/4 ''/a,S ZJr <br /> T N, 1 E (o W <br /> PROPERTY OWN7ER'S MAILING ADDRESS LOT# I BLOC # <br /> Z ,/ '. Q <br /> CI Y,STATE ZIPCODE PHONENUMBER SUBDIVISION NAME OR CSM NUMBER <br /> W1. 94'9 3 _ L <br /> II. TYPE OF BUILDING: (Check one) ❑State Owned El CIT AGE NAR ST ROLA[r ��n <br /> 11l.V <br /> ❑ Public X1 or 2 Fam. Dwelling—#of bedrooms PAIMUEL I AX NUMBER(5) <br /> III. BUILDING USE: (If building type is public,check all that apply) -14�` _ O' -406 <br /> 1 ElApt/Condo vV <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 ❑ 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 Bit applicable) <br /> A) 1. ❑ New 2. lLY Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System Z __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 /> 1eepage Bed 21 ElMound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> , <br /> 1 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.ABSOIRP.AREA�g �q13.ABSORP.AREA 4. LOADINGRATE 5. PERC.RATE 6. SYSTEMELEV. 7. FINALGRADE <br /> REQUIPR PO ED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 0 Feet Feet <br /> VII. TANK CAPACITY I Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tan strutted <br /> Se tic Tank or HoldingTank <br /> Litt Pum Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEME <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached p ans. <br /> Plumber's Name(Print): Plumber's Signature:( o S ps) MP/MPRSW No.: Business Phone Number: <br /> 1L <br /> P mber's Add ress(Street,City State,Zi Code): <br /> E 1 <br /> IX. COUNTY/DEPARTMENT USE ONKY <br /> ❑ Diaapprdved Sanitary Permit Fee(Includes Groundwater Date IssuedIssui nt Sig ur (N S mps) <br /> Approved ❑ Owner Given Initial IFS} c.. Fee) t5 <br /> Adverse Determination 'Tj _ `- <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Ow er,Plumber <br />