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on coy ) <br /> SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTY <br /> 15 V"e <br /> ST ESANIT YPERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ) y�� aC'') 1'-t,a, ,q, <br /> 8'%x 11 inches in size. Check if revision to previous application <br /> —See reverse side for instructions for completing this application. sT TE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNERnn PROPERTY LOCATION <br /> t 1Q ,.c O+ So ekn V Lt/% /��'/a, S T j , N, R I (,_&s er) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOC # <br /> b o 23 <br /> CITY,STATE ZIPCODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> S I r�r ul Z /S 3q'?-za 7j <br /> IL TYPE OF BUILDING: (Check one) State Owned VILLAGE GILL NEAREST ROAD <br /> {�l : S( j..,e h11 <br /> .X Public LJ 1 or 2 Fam.Dwelling-#of bedrooms— ARCELTAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo ll <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 Merchandise: Sales/Repairs 11 ❑ Re taurant/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.N 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 LJ 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 13.ABSORP.AREA 14. 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 Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank c(rHolding Tan 1� r G <br /> Litt Pum Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for'nstallation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plum er's Signature MP/MPRSW No.: Business Phone Number: <br /> N-e(S No mps) Yu P S 7_F ( <br /> Plumber's Address(Stre t,City,State,Zip Code): <br /> -18 TS C b F' Wt UU <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(includes Groundwater Date issued Issuing ga Si natur ( o mps) <br /> KApprovetl ❑ Owner Given Initial ``,�('s�u n pe Fee) U r <br /> Adverse Determination $ tv ` l� <br /> X. CONDITI NS F APPROVAL/SEASONS FQR QISAPPRQVAL: <br /> . 1 �es� 1 5 �� C\k )e <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,0 ner,Plumber <br />