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; .ViT SANITARY PERMIT APPLICATION <br /> `h� cou ry \ ' <br /> In accord with(LHR 83.05,Wis.Adm. Code <br /> STAT jr PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than o��_nj�S 3 <br /> 8'%X 11 Inches In size. heck 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 /> PROPERTYOWNER PROPERTY LOCATION <br /> Dili O Q % Ya, S Ia T Lh N, E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# (`J BLOCK# �1 <br /> SSS ENRMAS AV. N . 6 + <br /> CITY,STATE ZIP CODE I PHONE NUMBER SU (VISION NAME Or�CSM(�UMBER <br /> IL1W eC MN • SSo 2. 6/z- 30-0 �S�Is C�.K�2slo�'e <br /> IL TYPE OF BUILDING: (Check one) El state Owned VILLAGENEARE T ROAD <br /> Kc,n►JD S(_ <br /> El Public g 1 or 2 Fam. Dwelling--#of bedrooms Z PC WARREWL TAXNUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) ojo-C4-- )- <br /> 1 ❑ Apt/Condo l <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outcl or Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Rest,-urant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Othe : Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. ❑ New 2. L Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System I 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 ElMound 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 612.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE5. PERC. RATE 6. YSTEM ELEV. 7. FINAL GRADE <br /> REO RED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> -3dO Z- 1q3Z 7 3. 1 Feet JS•(o Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- teel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank ))SLl F-1 F1 <br /> Lift 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 pla ns. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> .gJC141490a4*,a 3 2U 7167 U (57 <br /> PI mber's Address Street City,S te,Zip Cod : <br /> Z-7-760 wy 35- r_a5`r i, 3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> �//i [-] Disapproved Sanitary P@rmit Fee (Includes Groundwater ate IssuedIssuing g t ignatur (No ps) <br /> �,i Approved ❑ Owner Given Initial k-F Sur e Fee) ` \ <br /> Y ` Adverse Determination y <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owns r,Plumber <br />