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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTY <br /> STAT S NIT \YPE-RMMIT#,cb,15 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 111 o <br /> 8'%X 11 Inches In size. ❑ Check it revision to previous application <br /> -See reverse Side for Instructions for Completing this application. STATE PLAN I.D.NUMBE / <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. S-EP+q -aDc17O <br /> PROPERTY OWNER PROPERTY LOCATION <br /> YaT (QIR '/a '/s, S T,31, N, R j6 E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 3 tA1J <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> WE8E2 W� '8`i3 866 o L DI <br /> 11. TYPE OF BUILDING: (Check one) Lml CITY NEAREST ROAD <br /> �/ ❑ State Owned VILLAGE: t�o TOWN OF CO- fD. A <br /> ❑ Public JK 1 or 2 Fam. Dwelling-#of bedrooms PARCEL TAX NU BER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) (:98 - <br /> 1 ❑ Apt/Condo IIIJJJ�����w <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranUBar/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 3o ❑ Specify Type 41 ❑ Holding Tank <br /> 12 ❑ Seepage Trench 22 Ll 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 /> 1.�Q� REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> I` 375 375 /()0-(- Feet b2•$S 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 low I <br /> Lift Pump Tank/Siphon 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): PIWnber's Signature: oStamps) MP/MPRSWNo.: Business Phone Number: <br /> o nl .W 3gZ_4 A5 <br /> Plum bar's Address(Street,Ci ,State,zip code)- <br /> Ww 35 WF-135X ;fe W • M <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved ISanitary Permit Fee(Includes Groundwater a e sue Issui A nt Signatu a(N Stam sp ) <br /> •Approved <br /> El Given Initial A—\ ur rge Fee) Q '[ �r ( <br /> Adverse Determinati2 n <br /> X. CONDITIONS OF Ar,n, tf-'pE4CgONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUION: Original to County.One Copy To:Safety a Buildings Division,Owner,Plumber <br />