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I J <br /> SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code co Nrr <br /> STATE SANITARY PERMIT A <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than IEA% a3u_ <br /> 8'b x 11 inches in size. V <br /> Check if revision to previous application VQ <br /> -See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> 14. C SNDCR_% '/4 ''/4, S 32 T qD , N, R & E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCI # <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> LUCK W1 . 4853 /5 )q72-%W ZEEFFRLES FQ <br /> II. TYPE OF BUILDING: (Check one Lj CITU NEAR ST ROAD <br /> State owned O VILLAGE Q:j=WO :� �p ^^L. 1 5r- <br /> Public JK 1 or 2 Fam. Dwelling-#of bedrooms PA x NUM ) W lV <br /> 111. BUILDING USE: (If building type is public,check all that apply)-Q, \_ G <br /> 1 ❑ Apt/Condo 1 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Res aurant/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. lzSl 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 /> 11Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ElHolding 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 PER7 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 3O0 4zq `f32 . 7 Feet 14. 0 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New A tin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdina Tank <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached p ans. <br /> Plumber's Name(Print): I Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> lc P DN u 3'>lZ6 1� S6&_ 7)S7 <br /> Plumber's Address(Street,City,State,Zip Code: <br /> 2?760 gw35 WMITER WI- 91813 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary P rmit Fee(includes Groundwater ae ssue Issuing g lSgna o mps) <br /> 1p� ,,, �ur�nerge Fee) <br /> pproved ❑ Owner a Determi al �y 1 t p^(,t,,) <br /> Adverse Determination ---��--CC J L1 LJ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Ow er,Plumber <br />