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SANITARY PERMIT APPLICATION <br /> r�7�lnr� In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STATE SANITA PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑C��� �30� <br /> 8'%x 11 inches in size. <br /> 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. SCH -CaLtN <br /> PROPERTY OWNER PROPERTY LOCATION <br /> e,4 /_ N e r.5 /4 '/4, S 9 T �/, N, R �Y E (or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> -3/ vs3 6j�6L, .0 K Or,v E /01--/ G Lr <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 715_ <br /> ITY <br /> If. TYPE O BUILDING: (Check one) ❑ State Owned O VILLAGE :G)e6� �pk NEAREST ROAD <br /> /tf 4ieE6 Gk <br /> IS Public ❑1 or 2 Fam. Dwelling-#of bedrooms— PAR EL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) Oaf :5-10 <br /> 10 6lb Oe <br /> 1 ElApt/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 /> 11Seepage Bed 21 ElMound 30 ❑ Specify Type 41 El HoldingTank <br /> 12 6 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. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED AREA <br /> ft.) PRcOPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> �' yS 9aa /7 r 93'7 Feet 1 96,1 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of <br /> Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New xistin Gallons Tanks Concret glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank /V40 I �Yo' "- <br /> LiftPum Tank/ i hon Chamber /orb /ti Do / .5 41_1 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,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 mps) 41P/MPRSW No.: Business Phone Number: <br /> � <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Po 60 -,.5- Siy Si/ c.J <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> k�j <br /> ❑ Disapproved Sanitary Permit Fee includes Groundwater ae suedsIssuing g tSignatur ( oSW ps) <br /> Approved E] Owner Given Initial Surcharge Fee) ll [I <br /> Adverse Determination /�L% <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 />