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SANITARY PERMIT APPLICATION p <br /> In accord with ILHR 83.05,Wis.Adm.Code CTY <br /> l O 3 I 1 <br /> lf4rn � p <br /> STATE SANITARY PERMIT# <br /> � <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than Ol f 46 73 <br /> 8'%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 /> Sll*2r X61/a �C'/a, S 3 7 T'16, N, R &(&r <br /> PRQPI=!TY OWNER'S LI G DDRESS LOT# BLOCK# <br /> /(T�/lT�/ ti <br /> CITY,STAT ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Cr' hl 547-z_ 141z )!S 3 tel CSIn V S_ -Rs Ger 1 I <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned VCITYILLAGEd <br /> ' '/ NEAREST+� <br /> :J� Sal <br /> ❑ Public X1 or 2 Fam. Dwelling—#of bedrooms AR LTAX NUMBER(b) <br /> III. BUILDING USE: (if building type is public,check all that apply) I a_ 4,)-3 0 ' 600 <br /> 1 ElApt/Condo L 7 <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 X 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 4. LOADING RATE 5. PERI.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) G�p / ELEVATION <br /> Q LT1rT�/} �T/3 • 7 �� !O, 1 Feet �O� Feet <br /> VII. TANK CAPACITY Site <br /> in alions Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks <br /> strutted <br /> e lit Tan rHoldin Tank <br /> Lift Pum Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for hilstallation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plum er's Signature: N mps) MP/MPRSW No.: Business Phone Number: <br /> 2GS o-er � S7 / 6 <br /> Plumber's Address(Street, / <br /> ity.State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a 1,1 111IssuinI,Ag Signa re IN ps) <br /> Approved ❑ Owner Given Initial �o c <br /> TTT"` Surcharge Fee) z <br /> AdverseD termination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBU6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />