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-- SANITARY PERMIT APPLICATION COUNTY <br /> M IR <br /> ���� In accord with ILHR 83.05,Wis.Adm.Code <br /> STAT SAGNIT99RY ERMIT ,,1 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �Qc�Oy� a� <br /> ❑ Check if revision to previous application <br /> 8'%x 11 inches in size. <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 lt)PROPERTY LOCATION <br /> �'/a !L) '/s, S �6 T3�, N, R�Jy E (or) <br /> Ken Luke LOT# el_oCK# <br /> PROPERTY OWNER'S MAILING ADDRESS _ <br /> 11097 Crosstavn Road <br /> CITY,STATE 21P CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Grantsbur WI CITY / NEAREST ROAD <br /> II. TYPE OF BUILDING. (Check one) ❑ State Owned ❑ VILLAGE:/�cOG� �j er <br /> ❑ Public [91 or 2 Fam. Dwelling-#of bedrooms PA CELTAX NUMBER(s) <br /> 111. 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 ❑ 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 /> ❑ Repair of an <br /> A) 1. ❑ New 2. ® Replacement 3. ❑ Replacement of 4' ❑ Existing System 5 Existing System <br /> System System Tank Only 9 <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 El seepage Bed <br /> 21 ❑ Mound 30 ElSpecify Type 41 ® Holding Tank <br /> 42 ❑ pit Privy <br /> 12 ❑ Seepage Trench 22 ElIn-Ground43 ❑ Vault Privy <br /> 13 EJ Seepage Pit Pressure <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY-1 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5.danPERC/inch)E 6. SYSTEM ELEV. 7' ELEVAT ON E <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) <br /> YS.n -- -_ Feet Feet <br /> CAPACITY Prefab. Site Fiber- Exper. <br /> VII. TANK in ailons Total #of Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> INFORMATION New istin Gallons Tanks structed <br /> Tanks Tanks - <br /> Se tic Tank or Ho Win Tank <br /> Lift 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 /> :(N tamps) <br /> MP/MPRSW No.: Business Phone Number: <br /> Plumber's Name(Print): Plumber's Signature <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTYIDEPARTMENT USE ONLY Issuin g tSignatu e N to ftp ) <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater e e ssue <br /> Surc ergs Fee) `\_ <br /> pproved F-1owner Given Initial Vl <br /> 111111��������`��` Advers Determine ion <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber — <br />