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SANITARY PERMIT APPLICATION <br /> ar�ri.i ie9ft COUNTY <br /> r.a�ln� In accord with ILHR 83.05,Wis.Adm.Code <br /> rn <br /> STATE NITARY RMIT# ��J� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than 2 ([ 19 <br /> 8%x 11 inches in size. ❑ C eck if revislo to previous application <br /> -See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTYOWN PROPERTY LOCATION <br /> e �CVa4 Sov SV 11a Ij 6%,S T78 , N, R <br /> PROPERTY OWNERS MAILING ADDRESS LOT# BLOCK# <br /> 114-7-7 C d <br /> CI ,STATE t ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> lF t d a <br /> If. TYPE OF BU ING: (Check one) <br /> ❑ State Owned 11 CITY e NAESTROAD <br /> 3 VILLAGE O <br /> Public 77 (U(bdpttvr TN <br /> r <br /> 2- A EL <br /> TAX NUMBER(5) <br /> Ill. 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 ❑ 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 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) p ELEVATION <br /> ,)v -7.;)t� /4.S Feet 99,_�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 structed <br /> Se tic Tan or Holdin Tank 1060 If IAI I P -0 <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. 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): Plumb/�rs��Siggnature:(Ng ;,,, MP/MPRSW No.: Business Phonee Number:' /l�lS <br /> Plumber's Address(Street,City,State,Zip Code): <br /> $v S- FJ , Dr <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ DisapDroved s760. <br /> nt[ ry Permit Fee(Includes Groundwater Date IssuedIssui A ants (No Stamps) <br /> / 0 �Surcnerge Fee) �-/Y� <br /> AApproved ❑ Owner Given Initial L� <br /> Advers 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,Owner,Plumber <br />