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0Y1 <br /> SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis. Adm.Code COUNTY a f>et <br /> STA SANIT RY PERM\tIT'# .__. <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than I^r.nTkI aIT I(�.� <br /> 8%x 11 Inches in size. ;heck if revlsion to previous ap lication <br /> —See reverse side for Instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PR7TY OWNER PROPERTY LOCATION <br /> S ' T N, 11 E (or <br /> PRO15ERTY OWNER'S MAILING ADDRESS LOT# <br /> 7 �tflivG $on/ 7.7'9eLkJ <br /> CITY,STATE IZIP CODE PHOIQE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> N�2a A11 . 1 71Z 3 SC—l7`/N 11 CITY Sum/ <br /> It. TYPE OF BUILDING: (Check one) ❑ State Owned El VILLAGENEAR ST ROAD <br /> .11JOtesonl ,qe L �PoA-i� <br /> ❑ RLTO NOF* <br /> Public V41or2 Fam. Dwelling—#of bedroomspni PARCEL TAX NUMBER(ti) <br /> III. 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 ❑ Out oor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Res urant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Ser ice Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: ( heck my one in line A. Check line B if applicable) <br /> A) 1. ❑ New 2. 4IReplacement 3. ❑ Replacement of 4. ❑ Reconnection ofepair of an <br /> System stem Tank Only Existing SystemtEx1st <br /> ing System <br /> B) % Sanitary Permit was previously issued. Permit# IS Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 151 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. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft) (Gals/day/sq.ft.) (Min./inch) / y ELEVATION <br /> D r 7"� Feet /`7� Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- <br /> Steel glass Plastic App. <br /> Tanks Tanks strutted <br /> Se tic Tank or HoldingTank 756 7_ol, 0— i)u <br /> Lift Pump Tank/Siphon Chamber O51<L% Q1f <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached pl ans. <br /> Plumber's Name(Print): Plumber's S <br /> jan4ture: o Ste MP/MPRSW No.: Business Phone Number: <br /> n�9F r r > o 7Z 71) <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 3 , Zd - SZEP�3 <br /> IX. COUNTY/DEPART ENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee(is ludas Groundwater a e ss Issuing g t Signatu a IN S ps) <br /> Approved F-1Owner Given Initial rT1' I <br /> Adverse Determination `� ` Il <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety B Buildings Division,Ow er,Plumber <br />