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SANITARY PERMIT LICATION `y) � ' t ' <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY C)J <br /> STATE SANR j PT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than L(rJ( <br /> 8'%x 11 inches in size. LJ 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. -)- p o <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Qrvr� r�}�w,SawS t -t +% %, S 10 T 39, N, R / &(W) W <br /> PROPERTY ER'S MAILINCI ADDRESS LOT# BLOCK# <br /> 3o L. 7.k` <br /> CITY,STATEZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER onneir <br /> Low't s o) - V.A 18z- <br /> Ill. <br /> zII. TYPE OF BUILDING: Check one CITY NEAREST ROAD <br /> ( ) State Owned VILLAGE <br /> Public 1:11 or 2 Fam. Dwelling-#of bedrooms— PARCELTAX NUMBER(S) ,A <br /> Ill. BUILDING USE: (If building type is public,check all that apply) 100 <br /> oajIf- 31 to- a%--s <br /> 1 El 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. ® Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only , Existing System xisting System <br /> B) Sanitary Permit was previously issued. Permit# 333 <br /> 6 Date Issued 15 S <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 ® Seepage Bedl�i��1 21 El Mound 30 El Specify Type 41 El Holding Tank <br /> 12 ❑ Seepage Trenc J/ 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 /> REQUUIIRED, (sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> (.00 olo'tf &4 • 7 mov to VA q4.(o Feet 94 L. Feet <br /> CAPACITY <br /> VII. TANK #of Prefab. Site Fiber- Exper. <br /> in allons Total Manufacturer's Name Con- Steel Plastic <br /> INFORMATION New ExistingGallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank l <br /> Lift Pump Tank/ -oo I $op t <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,y1XICsponsibility for installation o he onsite sewage system shown on the attached plans. <br /> PlumberEXCAVATIO mbe 's Signatu .(No Stamps) bWMPRSW No.: Business Phone Number: <br /> jiPt <br /> N6228!2nM Line Rd. fie? 7 <br /> Plumber's Addr , ip Code): <br /> (715)635-7482 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date I ued Issuing Agent.2rgiriatilifef t mps) <br /> Approved ❑ Owner Given Initialt) Surcharge Fee) <br /> Adverse Determination 5 LGA <br /> X. CONDITIONS OF APPROVAL/REASONS FOR PROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />