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SANITARY PERMIT APPLICATION <br /> iii,%■■ ■■uii+ COU TY <br /> vna-InIIn In accord with ILHR 83.05,Wis. Adm. Code <br /> STA SANITRYPERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than � 3 � <br /> 8%X 11 IDChe3 In size. heck 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. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> �/'c se_4le '/4 ''/4 S 7 T VO, N, /d E (or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT BLOC # <br /> 19790 vN;�e�s:/ Au r.e7 a <br /> CITY,STATE ZIPCODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> /ST Pgr��i� A, T PlIoe_S <br /> If. TYPE OF BUILDING: (Check one) CITY NWN EAR ST ROADA <br /> State Owned p VILLAGE aik`G Mo u, R) <br /> ❑ Public �S, or 2 Fam. Dwelling-#of bedrooms!2_ PAR ELTAXNUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) ac„ - cj y�) _ _ ;?C)o <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ OutcloorRecreational 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. ® 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 ❑ 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 /> 7 3 <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> C c O ya y y3 .6 9 "5` Feet 96 Feet <br /> VII. TANK CAPACITY Site <br /> In_ allons Total of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank Zfa jam' /VC <br /> Lift Pump Tarion Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,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 /> Plumber's Address(Street,City,State,Zip Code): <br /> �O .6eiX j/5/ S'. /`cici 1v'� jS�B'72 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Inclutles Groundwater Date issuedIssuing Sig at (N St s) <br /> Pq Approved Sul r Fee) <br /> / <br /> ❑ Owner Given I`�(cV[,; '\_/_t/ <br /> Adverse Determination l A� c <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 r,Plumber <br />