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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code cou TY <br /> STA A��jY PERMIT$ <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8%x 11 inches in size. ❑ heck if revision to previous application <br /> -See reverse side for instructions for completing this application. STA E PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Z_-a e A AJde/'SO/L) '/4 '/4, S TV 0, N, R / E (or) <br /> PROPERTY OWNER'S MAILING ADDRESSti1J. 3#joc1 G,, BLOCK# <br /> A <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> esu ass!l3 6/zLJ,tea-7/6 <br /> 11. TYPE OF BUILDING: (Check one CITY 7 NEAREST ROAD <br /> State Owned ❑ VILLAGE : S ��y T/ <br /> �7 C J <br /> ❑ Public L'J 1 or 2 Fam. Dwelling-#of bedrooms PAR EL Ax NUMBE ( ) <br /> III. BUILDING USE: (If building 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: (Checkonlyone in line A. Check line B if applicable) <br /> A) 1. E1 New 2. IJ 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 M 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. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> � <br /> O Y A / y 3 oZ / --� /7 Feet yy' T Feet <br /> VII. TANK CAPACITY Site <br /> in atlons Total #of 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 Tank /O /G+� RrU <br /> Lift Pump Tanta er 6PV — OV <br /> Vlll. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached r lans. <br /> Plumber's Name(Print): / Plumber's <br /> Signature:(No Stamps) WUMPPRSW No.: Business Phone Number: <br /> Plumber's Addrreess(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> LlDisapproved Sanitary Permit Fee tlncwdea Groundwater ee IssuedIssuingA Si at r ( oSt mps) <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial `�„-'�-GC <br /> AdverseDetermination ksb / N <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(R.oB/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Ow er,Plumber <br />