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54- SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COU 4TY <br /> STA SANIT(`RY PERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than �3 IAT <br /> r]nj�a <br /> 834 X 11 Inches In size. heck if 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. S _S <br /> PROPERTY OWNERERTY LOCATION �j <br /> AVW 1n�WKfl P OP '/4 Y4, S1-3 T /p, N, I E (or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BILOCP # <br /> 112-92- r_9V_S-M14 'RD <br /> CITY,STATE I ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> �KAMIL 1 5`t 3`f o 1015 6M-1,S0 <br /> It. TYPE OF BUILDING: (Check one) CIN NEAREST ROAD J <br /> State Owned O ILLAGE O00 <br /> ❑ Public r,1 or 2 Fam. Dwelling—#of bedrooms ARCEL LT <br /> NUM R( ) <br /> III. 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 ❑ Out 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. TY�PyE�'OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1.1< 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 21Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 El 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 j2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> rn REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 37(o .Z 3 5- 83 Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 000 <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 p ans. <br /> Plumber's Name(Print): Plumber's Signature:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> s 42b 7K 866- YIS <br /> lumbers Address(Street,City,State,Zip Code): <br /> 21 35' WOW W I . 5'�0 <br /> IX. COUNTYfDEPARTM NT USE ONLY <br /> E: Di: <br /> Sanitary Permit Fee(includes Groundwater ate ssue Issuing g Sig atur ( o mps) <br /> 11CI Approved ❑ Owner Given initial ry�harge Fee) <br /> '\ Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SB66398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Ower,Plumber <br />