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.~1. 11M SANITARY PERMIT APPLICATION <br /> r�n�91lnIn accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STAT SANITAX)PERMIT#_ � <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than el�kc�id a0 O <br /> 8'%x 11 inches in size. ❑ Check if revision to previous application <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 PROPERTY LOCATION <br /> Zl EMER '/4 /4, S 3S T 0, N, R /S E(oro <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 5 L 3 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION ME OR CSM NUMBER <br /> EBSTER V O L_- I . r} <br /> 11. TYPE OF BUILDING: (Check one) ❑State Owned VILLAGE'TY <br /> NEAREST ROAD <br /> S�1uCs o S- S+F <br /> ❑ Public -R1 or 2 Fam. Dwelling-#of bedrooms 2 PARCEL TAX NUMBER(S) <br /> III. BUILDING USE: (if building type is public,check all that apply) �\�.— 9a3-r—OS 000 <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. El New 2.k�l 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 X Holding Tank <br /> 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fi1I <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PE7 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRE Min./inch) ELEVATION <br /> �O Feet Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xistin Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank 2-00 <br /> Lift Pump Tank/Siphon 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) MP/MPRSW No.: Business Phone Number: <br /> 44 n oPK1nr 3`ljZ 'T1s' S6 - `{lS7 <br /> Plumber's Address Street,City,State,Zip Code): <br /> ff w 3S yjjEiir 3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e ssue issuingA nt SignaPIE <br /> 19 Approved ❑ Owner Given Initial U � r- Surcharge Fee) <br /> Adverse Determination UUOJ 4:- ,-q(( <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: o l <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />