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SANITARY PERMIT APPLICATION <br /> ie� COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STAT�Ik ya)PERMITi: c4904 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than l�c�d wd <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 /> PROPERTYOWNER PROPERTY LOCATION <br /> 790W G11n46L vn %, Sly T Q, N, R E (o )W <br /> PROP TYOWNER'S MAILING ADDRESS LOT# BLOCK# <br /> Ce► T02,QIU.12, Ro - Pct (-L 3 <br /> CITY,STATE ZIP CODE PHONE NU ER S <br /> LtJ. 51*L11 Z - T gO.I&. I . 0A000 <br /> It. TYPE OF BUILDING: (Check one) CITY N REST ROAD <br /> State Owned O VILLAGE: Kj �up t f50FZ2 TOWN OF.- <br /> . C <br /> ❑ Public K 1 or 2 Fam.Dwelling—#of bedrooms 2PARCEL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) H <br /> 1 ❑ Apt/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.XReplacement 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 ?� 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 DAI 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQ�U(IRED AREA <br /> ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) p / �/ ELEVATION <br /> 500 I`Lgj2 ! 1 b' ! Feet • L.—reet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncreta Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Se tic Tank or Holdin Tank <br /> Lift Pum Tank/Si hon Chamber 40 <br /> VIII. RESPONSIBILITY STAT9MENt <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 Sta ps) MP/MPRSW No.: Business Phone Number: <br /> AAf5 All <br /> Plumber's Address(street,City,State, Co : <br /> 2_-7-%,0 Zi d n 3s S?c R jil . 13 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Re Issued Issuin A en[Signa r (N Sta s) <br /> fS r ergo Fee) <br /> InkApproved ❑ Owner Given Initial <br /> Adverse Determination V <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />