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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTYI <br /> _ if 1, <br /> STAT SANITAR ERMIT-�#�\\\,A, �J <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ Jd'�6� CNS J 1 <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 /> PROPERTYOWNERII PROPERTY LOCATION <br /> {M <br /> t I ' k L2 n m N IV W%S E t%, S T3 , N, R <br /> PROPERTY OWNER'S MAILIN ADDRESS LOT# BLOCK# <br /> _7q-7(o L Oov' . ( <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Ed �vkc M n IS `t'3 t Z 2_1)-Yo73 <br /> II. TYPE OF BUILDING: Check one CITY NEAREST ROAD <br /> ( ) State Owned f7 VILLAGE <br /> IlrFfeo/' <br /> ❑ Public ®1 or 2 Fam. Dwellings of bedrooms� OWN TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) y -a aoy- 09-b <br /> cn <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. 1 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 /> 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 DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 3c�� REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) p ELEVATION <br /> Ya / 7. Feet /O• Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> OD <br /> Tanks Tanks structed <br /> e tic kor HoldingTank X 7Sd <br /> Lift Pum Tank/Siphon Chamber <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): P mbei s Signatur':IN tamps) MP/MPRSW No.: Business Phone Number: <br /> Pe is wt- NP 7/ ' ,966- o <br /> Plumber's Address(Street,City,State,Zip Code): <br /> C d. D l�t1eLi der <br /> Y/ s`F <br /> IX. OUNTDEPARTM NT USE ONLY <br /> rr�� ❑ Disapproved Sanitary Permit Fee(includes Groundwater late IssuedIss ' g gent Sign r (NoS mps) <br /> IIRApproved ❑ Owner Given Initial (_meq oercharge Fee) 1 <br /> T Adverse Determination JL✓ O <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />