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' SANITARY PERMIT APPLICATION <br /> v�<AACOUN Y <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> 114 <br /> n e4+ <br /> 7cil <br /> SANITAf>,YPERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than � \JJ Ppll''��JJ fj� <br /> 8'h x 11 inches in size. <br /> eck ifrevision 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 /> ROPERTY OWNER PROPERTY LOCATION ry <br /> erg me kR I ke N—C v4 t.(/i/4,s (rte T3. , N, R /,S'f-Eer <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# ^ BLOCK <br /> o W. s . ctv l A ire. P\ 6C <br /> CITY,STATE I ZIP CODE I PHONE NUMBER SUBDIVISION NAME O CSM NUMBER <br /> S4-01 n4fr vN rk L5,1zoi z ( 91 -&03o CSS <br /> El CITYIt. TYPE OF BUILDING: (Check one) El State Owned VILLAGE NEARE ROA4QWUOFD <br /> o l le i Z <br /> ❑ Public ®1 or 2 Fam. Dwelling—#of bedrooms PARCEL TAX NUMBER(S) <br /> 111. BUILDING USE: (If building type is public,check all that apply) —Ua- <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 ❑ Resta ranVBar/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 Bit 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 ❑ 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 D71 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. S STEM ELEV. 7. FINAL GRADE <br /> SREQUIRED(sq.ft.) PROP SED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> © t/O. 17! �T/ a • ZFeet Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of. Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tank's Manufacturer's Name oncrete Con- eel glass Plastic App <br /> Tanks I Tanks structed <br /> jj� tic Tan rHoldin Tank IP <br /> Pum Ta Si hon Chamber U <br /> VIII. RESPONSIBILITY STATEMENT . t <br /> I,the undersigned,assume responsibility fo installatio of the onsite sewage system shown on the attached pla is. <br /> Plumber's Name( rin Plu tier's Signature:(No raps) MP/MPRSW No.: Business Phone Number: <br /> e(s t 1VP s7 7/ T 6 0 <br /> Plumber's Address(Street,City,State ip Cod <br /> s c b ,� 3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Per�lt Fee(IncludFi Groundwater ae ssue Issuing Agen Signatur ( o Imps) <br /> �}} , �S_ yg(ge Fee) t <br /> pproved ❑ Owner Given InitialtF-(�surch� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Ownel,Plumber <br />