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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> RA <br /> STAT SANIT YPERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 834 x 11 inches in size. cI ieck 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 Q <br /> HELiIii nrK U — ST. CRD(X CO LLPIC(l '/4 '/4, S �$ T 3g, N, R I4 E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK <br /> T.O. Box 2131 2l L. S 2 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> ERTEL_ W1 .541345' L-tttio + SATHRE Su D - <br /> II. TYPE OF BUILDING: (Check one) 1:1 State <br /> State Owned VILLAGE CITYNEARES ROAD <br /> �7I alt.l. $p LN .❑ Public ISI 1 or 2 Fam. Dwelling--#of bedrooms 3 PAR ELTAXNUM ( ) � l �1 <br /> III. BUILDING USE: (If building type is public,check all that apply) l xm— C7 w o - �� 'J V <br /> 1 ElApt/Condo l l� <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. TYPPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. M 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 DTI 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6, SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./in/inch) ELEVATION <br /> 663 (o49 .-7 I a •0 Feet IOI.S Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xistin Gallons Tanks oncrete strutted glass App. <br /> Tanks Tanks <br /> Se tic Tank or Holdinot Tank 100, <br /> OQQ ( 5 <br /> Lift Pum Tank/Si hon 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.: I Business Phone Number: <br /> lc _jL26 IS" $66-gw <br /> Plumber's Address(Street,City,State,Zip Code): <br /> w 313 6esieR W 1• .54913 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved I Sanitary Permit Fee(Includes Groundwater a e IssuedIssuing Ag ig atu ( S ps) <br /> Approved ❑ Owner Given Initial `L� lt_(�S'yf�pq�rge Fee) <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />