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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COU 4TY <br /> STA ESilY E II-# / <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than s�/eld11 111//(- 6A <br /> 8'%x 11 Inches In size. heck ii revision to previous application <br /> -,See reverse side for instructions for completing this application. STA E PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> G o /o /0Cd344 ✓✓w Ya, Sao T /0, N, /5/ E(or <br /> PROPERTY O ERS MAILING ADDRESS LOT# BLOC # <br /> ,�8� 7h r,4 sh,r <br /> CITY,STATE ZIP CODEPHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 10r.4 60/ofl 7v a9- Gla <br /> Il. TYPE OF BUILDING: (Check one) CITY NEAR ST ROAD <br /> State Owned 0 VILLAGE: SGO <br /> v />v e, <br /> ❑ Public N1 or 2 Fam.Dwelling,#of bedrooms a PAR ELT NUMBER(S) <br /> III, BUILDING USE: (If building type is public,check all that apply) N .g- <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ outc oor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Res aurant/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. D'Al 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 Fj 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 41 cFELEVATION <br /> 60e) 6 0O 5` .,-3 Feet / 6, Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdin Tank �i� Y04) .S ,�tt <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 /> Plumber's Name(Print): Plumber's Signature:(No Stamps) QPIMPRSW Nq Business Phone Number: <br /> ie Y ho . I <br /> Plumber's Address Street,City,State,Zi?Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee(Includes Groundwater re Issued Issuing g tSjgnat re(No tamps) <br /> ZAroved �^ W#harge Fee) 11 (, <br /> pp ❑ Owner Given Initial fV\ <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety B Buildings Division,Ow 7 <br /> r,Plumber <br />