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8y1 <br /> SANITARY PERMIT APPLICATION r� <br /> E:1 ��:r'i In accord with ILHR 83.05,Wis.Adm.Code cou 4TY y <br /> STASANT RY PERM T# <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 it reJJJvision 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. �L,J <br /> PROPERTY OWNER PROPERTY LOCATION <br /> AlciWAI WA it '/< '/4, S 23 T$ , N, R P E(or W <br /> PROP RTY OWN R'S MAILING ADDRESSL, I LOT#7Z 13 BLOC # <br /> lW i <br /> WY,STATE ZIP CODE TPHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> yQi6qfv,5T6-R MA. 559v ? IANO Igao . 10 iv. <br /> IL TYPE OF BUILDING: (Check one Li <br /> CITY NEAR ST ROAD <br /> State Owned VILLAGE;�p <br /> ❑ Public ®1 or 2 Fam. Dwelling—#of bedrooms7-- PA ��� <br /> PAL TAX <br /> NUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) o ll) c& . O <br /> 1 ElApt/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: (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 19 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 5. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 Llog 1 ?jz- �jq,� Feet 7I Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New <br /> FF <br /> Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or HoldingTank '— <br /> Lift Pum Tank/Sipon <br /> 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): Plumber's Signature'L:(No tamps) MP/MPRSW No.: Business Phone Number: <br /> fOMPW 0 N5 � n (0 1� 15 <br /> Plumber's Address(Street,City,Stat ,Zip Codd): <br /> 27160 w -35 Wr WER W1 , 5`{x93 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ,r-1, ❑ Disapproved Sanitary Flermit Fee(Includes Groundwater e s ue Issuing Signatur ( o la ) <br /> tYl Approved �rtN't(�, ar0e Fee) <br /> P` ❑ Owner O <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,Ow at,Plumber <br />