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SANITARY PERMIT APPLICATION <br /> COUNTY <br /> In In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE ANI7A VPERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> STATEd <br /> 8'h 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. S94- 6`'013 <br /> PROPERTY OWNER PROPERTY LOCATION <br /> SE 1- O 6, '/+SYS} '%, S T 38 , N, R 4 E (or W <br /> PROPERTYOWNER'S MAILINGA DRESS LOT# BLOCK# <br /> Z714,53 1 NG go . <br /> CITY,STATE ( , ZIP COD 1 PHONE NUMBER SUBDIVISION NAME OR CS;NUMBER <br /> Il. TYPE OF BUILDING: (Check one) ❑State Owned L-I CITYVILLAGE: J NEAREST ROAD <br /> :1 1❑ Public M 1 or 2 Fam. Dwelling,#of bedrooms ARCEL TAX NU BER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) Oa-4\0\- lA V,?-,O <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.X 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 ElSeepage Bed 21 -9 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.pBSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> c�T <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) QQ ELEVATION <br /> .37s 74, /, 7- �� / S• 3 Feet 00._4�5_Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank --110001 )10 <br /> Lift Pum Tank/Siphon Chamber) — I� 1 tE &t2101-1 n <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,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 /> /<�} p Ns ZG 715 S7 <br /> Plumber's Address(Street,City, tate,Zip Code <br /> 2-7-Ago w 1,16 g)z L"13 <br /> IX. COUNTY/DEPARTME T USE ONLY <br /> F-1Disapproved I Sanitary Permit Fee(Includes Groundwater ate Issued Issu' g Agent ignat re(No Sta ps) <br /> Surcharge Fee) <br /> ,Approved ❑ Owner Given Initial Qjr�- <br /> Adverse Determination dco <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />