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SANITARY PERMIT APPLICATION <br /> UNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code cob uteri e f <br /> STATE SANITARY P1k9MIT#a <br /> -Attach complete plans(to he county copy only)for the system,on paper not less than E] '��'1/ J <br /> 8%x 11 inches in size. Ch kIfrevision previous application <br /> -See reverse side for instr ctions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. S9 - _)03S <br /> PROPERTY OWNER PROPERTYLOCATION <br /> ,i <br /> 44. n 1 / /t/W'/auL<,I'/a, S (>-IS T 37N, R ( 4-f&r)W <br /> PROPERTY OWNER'S MAILIN A)DRESS LOT# BLOCK# <br /> 33 W. 3t V • Lb-, D-- <br /> C TY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> �� tNl S fPt'L 316-g67t� <br /> II. TYPE OF BUILDING: (C eck one) ry, CITY NEAREST ROAD <br /> ❑State Owned O VILLAGE 14 <br /> [] Public W 1 Or Fam. Dwelling-#of bedrooms PAR LTAXNUMBER( ) <br /> III. BUILDING USE: (If builc Ing type is public,check all that apply) <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 8 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: (C eck only one) <br /> Non-Pressurized Distrib ition 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 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> RE UIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION Manufacturer's Name Con- Steel Plastic <br /> New xistin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks _ <br /> Se tic Tank Holdin Tan <br /> Lift Pum Tank/Siphon Chem <br /> Vlll. RESPONSIBILITY ST TEMENT <br /> I,the undersigned,assume esponsibilityfor i stallation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print: Plum is Signature:( S ps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Ziq Code): <br /> 7 r Q4,i PC/- e�os�r w fir&I <br /> I COUNTY/DEPART E T USE ONLY 1111 <br /> ElDisapproved Sanitary Permit Fee(includes Groundwater ae ssue Issui❑ entsign a(No Stamps) <br /> �L ee) / ^ <br /> Approved Owner Giv n Initial q� I C�j� F 11 Surcharge F <br /> Advers D termination —W 'w lilt <br /> X. 6ONDrr1ONS OF APP OVAL/REASONS FOR DISAPPROVAL: <br /> S8d6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />