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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code cou TY <br /> STA ESANIT RYPER\MIT# <br /> [ <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than -rr4j t)Lr? i cc <br /> 8'%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. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> c �wti z '/ara)/4, S 34 T 4z, N, R 14 W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCf,# <br /> Ss1 Fox �oA9 <br /> CITY,STATE ZIPCODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBS p <br /> 6t�f ;5V�0) e-5M /,Vw L'O ' l <br /> 1. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> 1 <br /> �7l ❑ State Owned ❑ VILLAGE : G <br /> ❑ Public /�11 or 2 Fam. Dwelling-#of bedrooms Z PARCELT&UMUti (b)C <br /> 111. BUILDING USE: (It building type is public,check all that apply) - y 1_S 1 -C�_ <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 ❑ 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 CK 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 DAY 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 4a1 <br /> '1-32— �r7 95. 7 Feet r17. Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name <br /> Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank /0xfo <br /> Lift Pump Tank/2! 4001 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the site sewage system shown on the attached P lans. <br /> Plumber's Name(Print):M�yy K Plu ei s Signature:( tamps) /MPRSW No.: Business Phone Number: <br /> SEPTIC & EXCAVATI <br /> Plumber's Addr 0C90ftq f8fflCode): <br /> Mr. W1 54MI <br /> IX. COUNTYID E ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e IssuedIssuin nt Signature(No Stamps) <br /> h <br /> Approved ❑ SOwner Given Initial � C-11_` arge Fee) <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Ow er,Plumber <br />