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SANITARY PERMIT APPLICATION COUNTY <br /> TDILHR In accord with ILHR 83.05,Wis.Adm.Code 4 I, <br /> • _� STATES ITARY P IT#19053 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than (p(.�� <br /> 81/2x 11 inches In size. ❑ Check if revision revious application <br /> –See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. O 7-5- <br /> PROPERTY <br /> -5PROPERTY OWNER PROPERTY LOCATION <br /> lV C e k4tels NW'/a Al E'/a, S T-SQ, N, R �( ) <br /> PROPERTY OWN R'S MAILING ADDRESS LOT# BLOCK# <br /> Ss- Crvsstoa_,n <br /> ITV,ST Tgg ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> bU W ` Si(vito ItT1'ITY! o <br /> 11. TYPE OF BUILDING: (Check one) ❑State Owned VILLAGE NEAREST ROAD <br /> N71 000 1t)er Dass A d. <br /> ❑ Public 1011 or 2 Fam. Dwelling-#of bedrooms— AR Ax Nu R( <br /> III. BUILDING USE: (If building type is public,check all that apply) #a -1;6 a� - �� -i eo <br /> 1 EJ ApUCondo <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. X 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 /> ��� REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of <br /> Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> strutted <br /> Tanks Tanks <br /> Septic Tank oldin Tan .�CTa'� tPSp/' <br /> Lift Pum Tank/Si hon Chamber <br /> Vlll. 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): Plu er's S nature:( o mps) MP/MPRSW No.: Business Phone Number: <br /> AJ <br /> ets KoeY PS7 �/ 7., - 6 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> GP r / r 89 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater ae IssuedIssuing ent Signature(No Stamps) . <br /> /3� �roharge Fee) — � %� <br /> Approved ❑ Owner Given Initial <br /> Adverse Determin tion <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plbb7)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />