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=C21L' HR SANITARY PERMIT APPLICATION <br /> couN <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITARY.?ERMIT#ICI_640 <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than 00-7031) <br /> 0-703i 1 I <br /> 8'h x 11 inches in size. Check it revision to previous application <br /> -See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. <br /> PROP TY OWNJER �r PROPERTY LOCATION / <br /> I� C C C %.5W'/a, S Ilo T 40, N, R 14 E(O <br /> PROPERTY OWNER'S MAI ING ADDRESS LOT# BLOCK# <br /> CITY,s1rATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> W 1 <br /> It. TYPE OF BUILDING: (Check one) CITY NEAREST OA <br /> ❑State Owned VILLAGE: D <br /> d <br /> Public ❑ -•#1 or 2 Fam. Dwelling of bedrooms— EL uMe M <br /> 111. BUILDING USE: (If building type is public,check all that apply) ` O ql�L— 63--700 <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 estauran 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. eplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System ystem 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 <br /> El Bed 21 Mound 30 ❑ Specify Type 41 El Holding Tank <br /> 12 ❑ Seepage Trench 2 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 DAI 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPO E4D(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEV ION <br /> 114 1147-0 , t I (� I • Z OS • Feet V Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Ho ding Tank K <br /> Lift Pump Tank/SI Dhon Chamber — k, 31 i i 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 ps) MP/MPRSW No.: Business Phone Number: <br /> (c o Klyd 3`i� ?rS 866- y157 <br /> Plumber's Address(street,City,State,Zip Coder <br /> 7_11 (6o H ,J 3S WeBS'f'ir_g W)- 54813 <br /> IX COUNTY/DEPARTMENT USEONLY <br /> ❑ Disapproved Sanitary Permit Fee(includes Groundwater ate ssue Issuing g t Sig ature No Stamps) <br /> Surcharge Fee) <br /> Approved Owner Given Initial 3Oo• �_J I- - j� <br /> Adverse Determination <br /> LLLYYY Ol a <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBO-6398(formerly Plb-67)(R.11/98) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />