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SANITARY PERMIT APPLICATION <br /> "we In accord with ILHR 83.05,Wis.Adm.Code cou, Tv � <br /> STA SANITkRYPERMIT#,_,,,/- <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than , '' `�Shy <br /> 8%x11 inches in size. vpe l_ _ r <br /> Check ii r ision to prev,ous application <br /> —See reverse side for instructions for completing this application. STA FE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> 10M 13LACK %a ''/a,S O T , N, R E(or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT , BLOC # GL <br /> s Ro. P� <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM UMBER <br /> smowER I.Sqi%oi 715 635.40 a , �p <br /> 11. TYPE OF BUILDING: (Check one CITY NEAREST ROAD <br /> State Owned VILLAGE: S /r pp <br /> ❑ Public 21 or 2 Fam. Dwelling—#of bedrooms ny <br /> 3 A LTIAAX N`U(M�BER( ) CJ IlY <br /> III. BUILDING USE: (If building type is public,check all that apply) /�A—q�16 —0� km <br /> 1 ❑ Apt/Condo w <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Out oor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Res aurant/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.MReplacement 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 N Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 0 Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER 72.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 4JVREQUIRED(sq.ft.) PROPOSED(sq.ft.) (Galls?/day/sq.ft.) (Min./inch) p ELEVATION <br /> 3 f0�0 . / I Feet 103•-1 Feet <br /> VII. TANK CAPACITY Site <br /> in <br /> 11 Total Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic APP <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank 0� <br /> Litt Pum Tank/Si hon Chamber 600 1 IoOO <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:Po tamps) MP/MPRSW No.: Business Phone Number: <br /> K4H,vp 43U, <br /> Plumber's Address(Street,City,State,Zip Co ): <br /> 2776o 35 3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary P rmit Fee(Includes Groundwater de Issued Issuing g nt ign t re o Pell <br /> Approved ❑ Owner Given Initial , Surc arge Feel <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owr at,Plumber <br />