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(� SANITARY PERMIT APPLICATION <br /> LI 0ILHR In accord with ILHR 83.05,Wis.Adm.Code CgyNTvd (l L <br /> STATE SANITARY PERMIT# 1 ZS-2 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than I MssZ0 <br /> 834 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 /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> V/0 N V, A0Falee 6b-414 �'/4, S T yo, N, R I�K kor <br /> PROPERTY OWNER'S MAILING ADDRESS LOT BLOCK# <br /> 193/0 W. 7Rv G Pf)kk Rb<)D � �� 3 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> i a aL C6 J -V/bo <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned VITY <br /> LAGE NEAREST ROAD <br /> Imo, ? : Seorr eT/l E' <br /> ❑ Public L'T1 or 2 Fam. Dwelling-#of bedrooms NL PAR EL AXBER(S) <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 ❑ 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. ❑ 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 eepage 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 DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> rT REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) n �7 ELEVATION <br /> T Feet J0,04, 7 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total 'of <br /> Prefab. Fiber- Exper. <br /> INFORMATION New xiss Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank OGYJ <br /> Lift Pump TanktSi 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) TICMRSW No.: Business Phone Number: <br /> 6r !S 635= ,>Sla <br /> Plumber's Address(Street,City,State,Zip Code): <br /> /PT. A S F<< L A E <br /> IX. OUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee includes Groundwater [Date Issued Issu' g gent Sign re(No Stamps) <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial �\U �— U <br /> Adverse Determination <br /> CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />