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� Corrt� <br /> ■Z�.-;.�� SANITARY PERMIT APPLICATION <br /> K• In accord with ILHR 83.05,Wis.Adm.Code cou TY n <br /> 4 <br /> BTANIc�RY PEFiM(T#�� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than i\ l_71` T N <br /> 6'r4 x 11 IOChea ID s128. k it revision to previous eppllcauon <br /> -See reverse side for Instructions for Completing this application. STATE PLAN I.D.NUMBER �- <br /> I. APPLI ANT INFORMATION—PLEASE PRINT ALL INFORMATION. SU <br /> PROPERTY OWNER PROPERTY LOCATION <br /> '/4 ''/4,S 'L3 T , N, E or W <br /> PROP RTYOWN R'S MAILING ADDRESS' StiJ LOT# r 13 BLOC # <br /> WS hgoevi <br /> C ,S ATE ZIP CODE J PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> cE SSD IAO qDD . 10 V.V. <br /> 11. TYPE OF BUILDING: (Check one) CITY <br /> SACK504 NEAR ST ROAD <br /> State Owned VILLAGE <br /> ❑ Public M 1 or 2 Fam.Dwelling-#of bedrooms <br /> IN. BUILDINGUSE: (1l building type Is public,check all that apply) 01a <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 E] Outc loor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Res uranVBar/Dining <br /> 4 ❑ Church/School B ❑ Mobile Home Park 120Service Station/Car Wash <br /> 5 ❑ Hotel/Motel g ❑ Otfice/Factory 13 ❑ Oth r: 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 ® Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 El HoldingTank <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 DAY 2.ABSORP.AREA 13,ABSORP.AIIEA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> �M REOUIRED(sq.tt.) PROPOSED(sq.ft.) (Gals/day/sq.h.) (Min./inch) ELEVATION <br /> *. 00 29 Z . 7 ,6 Feet 1411 Feet <br /> VII. TANK CAPACITY Site <br /> in aliens Total #of Prefab. Fiber- Exper. <br /> INFORMATION New isti Gallons Tanks Manufacturer's Name oncret Con- Steel glace Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <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:(No tamps) MP/MPRSW No.: Business Phone Number: <br /> I ARO i) h15 ,AIAe tt `Iz6 15 <br /> Plumber's Address(Street.City,stat ,Zip Cod <br /> znb0 w 36Wi5iWgR W t. 51 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ,�-j, Disapproved Sanitary,��e{r.,mn Fee(ImiludesGroundw ter e u Issuing Signalur ( o to ) <br /> T]D Approved ❑ Owner Given Initial �w -d <br /> V� A v rs �k'T <br /> X. CONDMONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-63QS(R.08R3) DISTRIBUTION: Original to County,One Copy To:Safety d Buildings Division,Ow r,Plumber <br />