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SANITARY PERMIT APPLICATION COUNTY <br /> V DILHR <br /> In accord with ILHR 83.05,Wis.Adm.Code BURN TT <br /> • _ STATES4NITAR ERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ja <br /> 8'%x 11 inches in size. ❑ c kit revlsio to previous application <br /> -See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> I,A )CNNA ,LYON N-il. Sis %, s20 T 40 N R1/ <br /> PROPERTY OWNER',§MAILING ADDRESS LOT# BLOCK# <br /> RTI BOX22b 2 NSA <br /> CITY,STATEZIP CODE I PHONE NUMBER SUBDIVISION NAME OR CSM N MBER <br /> HINKj�I,,Y 55037 - )��j In (�, L• <br /> II. TYPE OF BUILDING: (Check one) CITY AREST ROAD <br /> ❑State Owned VILLAGE ; ,SCOTT _cII,IS & CTH A <br /> ❑ Public ❑1 or 2 Fam. Dwelling-#of bedrooms? �f1iff4hUMB <br /> III. BUILDING USE: (If building type is public,check all that apply) ��,. n / �I _ -�� <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 /> 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 EM 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 LI c"P TO CONVi'NTIONAI SHALLO'J DRAINYI :LD <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 5. PER'.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Mir inch) ELEVATION <br /> 300 4.10 4.20 .72 3 92--7 Feet 94.6' Feet <br /> VII. TANK CAPACITY Site <br /> in alit Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank )M0 +'til E?SE?Y• S X <br /> Lift Pum Tank/Siphon chamber � 57 com 71 P A ON <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of 110 onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signat re: o Stamps) MP/MPRSW No.: Business Phone Number: <br /> ITL J. ?RGufD X393 715 71 635-7482 <br /> Plumber's Address(Street,City,Slate,Zip Code): <br /> HCR59 BOX 780 POGN:I:R,",!I 54801 <br /> ,IXI COUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater ate Issued Issuing Agent Sign tura(No to s) <br /> Surcharge Fee) <br /> Approved ❑ Owner Given initial w� `61661b <br /> Adverseamu' , 00 <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />