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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> cour �ij_� e <br /> STA-:E S I RY PERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than 7 � � <br /> 8%x 11 Inches In size. heck if revision to prevwus 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 /> PROPE TY OWNER PROPERTY LOCATION <br /> etq �\c,,r '/a ''/a,S Zg T 0 , N, R J& E (or W <br /> PROPERTY OWNER'S MAILING ADDREgV LOT# BLOC # <br /> 2 0B8 <br /> PCITY,STATE ZIP CODE PHONE NUMBER SUBDIVISIONUUTIER CSM MBr <br /> USTE2 � ie , <br /> mA <br /> CITY NEAR ST ROAD <br /> II. TYPE OF BUILDS IIN'�G: (Check one) ❑ State Owned VILLAGE N TOWN OF O <br /> 4 115- <br /> ❑ Public 1011 or Fam. Dwelling—#of bedrooms PARCEL TAX M RO TK_ ( 1_-s'no <br /> III. BUILDING USE: (If building type is public,check all that apply) �" ��1. <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 taurant/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. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. El New 2. (L,neplacement 3. 0 Replacement of 4. 0 Reconnection of 5.0 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 DAY 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 5. PERCi RATE 6 SYSTEM ELEV. 7' ELEVAFINAL ION GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) <br /> 3S po0 375- 3 S' I Feet Feet <br /> VII. TANKCAPACITY Site Fiber- Exper <br /> ino allons Total #of Prefab. . <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete strutted Con- Steel glass Plastic App <br /> Tanks Tanks <br /> Septic Tank or Holdin Tank �" <br /> Lift Pump Tank/Si han Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached Mans. <br /> Plumber's Name(Print): Plumber's Signature:(No S ps) MP/MPRSW No.: Business Phone Number: <br /> c A s 3` 7-(o 7/s %&-j'IS7 <br /> Plumb 's Address(Street,City,State,Zip Code). <br /> 277(60 Hwy 35 6857—CA W(- .5q-973 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ,,((� ❑ Disapproved Sanitary P rmit Fee(Iscludeag Groundwater <br /> water /a a ssue r-- Issuing A nt i a o mps) <br /> &pproved ❑ Owner Given Initial \y ©W /-a`-� <br /> Adverse Determination ` VV <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 6 Buildings Division,0 ner,Plumber <br />