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=° SANITARY PERMIT APPLICATION <br /> r&_'NL�nCO NTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> 1 Q <br /> STT SANITAAIY PERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than I�{Y O �l{ <br /> 8%x 11 inches in size. check/ir/re ck <br /> ion toprevious application S <br /> —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER S <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. d <br /> PROPERTY OWNER ,��"� � PROPERTY LOCATION <br /> C t.rl�vrV '/. ''/a, S T N, R E (or) <br /> PROP€RTY OWNER'S MAILING ADDRESS LOT# BLOC # <br /> fSS 'Z <br /> CITY,�STATE , 1 ZIP CODE PHONE NUMBER SUBDIVISION NALn ME OR CSM NUMBER <br /> fiJ�IVGR W I' S �� (�� G+Jt <br /> It. TYPE OF BUILDING: (Check one) ❑State Owned VILLAGE 'dNEA EST ROAD <br /> tl� <br /> ❑ Public X, ort Fam. Dwelling—#of bedrooms;gFAMUtL TAX NUMBERS) <br /> III. BUILDING USE: (If building type is public,check all that apply) �— <br /> 1 ❑ Apt/Condo L <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Out oor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Re auranVBar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Ser iice Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Oth r: 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 /> 11Seepage Bed 21 El Mound 30 ❑ Specify Type 41 El HoldingTank <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 7 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. FERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REO I1R7ED(sq.ft.) PRO OSED(sq.ft.) (Galls//day/sq.ft.) (Min./inch) ELEVATION <br /> '300A- 1 Z Feet 4' Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks / structad <br /> Se tic Tank or Holdin Tank <br /> Litt Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached pl ans. <br /> Plumber's Name(Print): Plumber's Signature:(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> f e 3qz 4 <br /> PI mbar's Address(Street,City,State,Zi codey. <br /> 47 <br /> -Lo893 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes crFee) ter ae ssue Issuing Ag [Signalur ( 0St ps) <br /> Approved ❑ Owner Given Initial �Ny`t1l Surcryafg�p Fee) ` <br /> Adverse Determination Cell <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBO-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Own r,Plumber <br />