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Can( <br /> �.� SANITARY PERMIT APPLICATION CO TY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> �f <br /> ST E SANITARY PERMIT#[r`� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than r()()3) �l, <br /> 8%x 11 Inches In size. Check if revision to previous application <br /> —See reverse side for Instructions for completing this application. STA E PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATIO <br /> PROPERTY OWNER PR LOCATION <br /> In 7}t /< 0/a AWN,, S ;? T 32, N, R /5 E (or) <br /> PROPERTY OWNER'S M LING ADDRESS LOT# BLOC # <br /> / 7,6 Y, J e s-r <br /> CITY,STATE ZIPCODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> El <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned ElVILLLLAGE t/. NEARS Ok e J <br /> L 9.Fo//<I Ke L rl <br /> ❑ Public [Al or 2 Fam. Dwelling—#of bedroomsR— PARCEL TAX NUMBER(b) <br /> III. BUILDING USE: (If building type is public,check all that apply) �J() \,- ,r b�� <br /> 1 ElApt/Condodo <br /> ❑ Medical Facility/Nursing Home 10 ❑ Out oor Recreational Facility <br /> 2 El Assembly Hall 6 <br /> 3 ❑ Campground 7 ❑ merchandise: Sales/Repairs 11 El Res auranVBar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Ser ice Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Oth r: 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 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 El 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 /> --C REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) C7 ELEVATION <br /> 0 /j/Z vc3 .;I. / h9 '7 Feet /tel Feet <br /> VII. TANK CAPACITY Site <br /> in allona Total #of <br /> Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank og YaU / -S'��"`° <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): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> f.✓,yo%. e4ll� -4 e /.. <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(ISulrucddeaitar9 roue water ate IssuedIssuing5�gn=ps) <br /> Fee <br /> Approved F-1OwnerGiven Initial \ ^t:Y <br /> Adverse Determination �} <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SB66398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Ow at,Plumber <br />