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SANITARY PERMIT APPLICATION <br /> ^' r■^ <br /> In accord with ILHR 83.05,Wis.Adm.Code Co INTY <br /> ST IT SA1NI�TTJRRYPERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than r \ .(���� <br /> 8bx11inches insize. checkirr ion to previous application o <br /> wee reverse side for instructions for completing this application. ST TE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. C"' - okO-?) <br /> PROPERTY OWNERfl PROPERTY LOCATION <br /> zol- �Z U e-,('77e,rJ� Co/ '/4 '/4, S T,73V, N, R E (or)® <br /> PRo TY OWNER'S MAILING ADDRESS LOT# BLOC # <br /> / o /_ic,>d 072 V 1-15— <br /> CITY, <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> R,c� L/1 - ! / sv86f3 Jr5 asv-7vys /°�.v Y sura/is <br /> II. TYPE OF BUILDING: (Check one StateOwned CITY 0 VILLAGE' NEA EST ROAD <br /> I la TOWN : �� e S etvjc, <br /> cJfc l r ,� <br /> ❑ Public 121 or 2 Fam. Dwelling-#of bedrooms 4- PARCEL TAX NUMBER(S) <br /> Ill. 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 E,Out r Recreational Facility <br /> 3 El Campground 7 EJ Merchandise: Sales/Repairs 11 ❑ aurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Wome Park 12 ❑ Ser ice Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Oth r: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check fine itif applicable). <br /> A) 1. ® New 2. ❑ Replacement 3. ❑-Replacement of 4. E]Reconnection of 5.❑ Repair of an <br /> System Systd,tn Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Permit was greviously issued. Permit# Date Issued <br /> V. TYPE OF SYSTEM: '(Check only 65111) <br /> Non-PressurizedOistribution Pressurized Distribution Experimental Other <br /> 11 ❑ SeepaA..Bed 21 M 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-F11I <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER7 2.ABSORP.AREA 3,ABSORP.AREA 4. LOADING RATE 5. FERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> ? RE_OUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> e3 70 <br /> Feet !U Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION Ne.. istin Gallons Tanks oncrete glass App. <br /> T lis Tanks structed <br /> Septic Tank or HoldingTank rOo /COG <br /> Lift Pum Tank/Si hon Chamber 600 60p K <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): Plumber's Signature:(No St ps) MP/MPRSW No.: Business Phone Number: <br /> l� s�✓e_ yds!>as 455�_1 <br /> PluFmJbeis Address(Street,City,State,Zip Code): a <br /> CD _757 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved I Sanitary Per it Fee(Includes Groundwater assn Issuing g tsi natur ( o mps) <br /> UkApproved Owner Given Initial Suroharge Fee) <br /> ❑ <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> Se� pwm <br /> issued ro-30-08 <br /> SBD-6398(R.08193) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Own r,Plumber <br />