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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COU Ty. <br /> STA ESANITAR ERMIT#-)3L_tA/„ <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than (1g rl�� 1 /Y� <br /> 8%x 11 inches in size. ❑ heck ifrevls' ntoprevious application <br /> -,See reverse Side for Instructions for completing this application. STA E PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> SE SG A % Y<, S Z6 T / , N, R S E (0 6) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOC # <br /> 0 Z(o LK• Rv - 37 3 3q <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVI ION NAME OR CSM NUMBER <br /> taN . ,Wt . �''1�30 101S I`1 VDl- Z0 203 in <br /> 11. TYPE OF BUILDING: (Check one) CITY NEAR ST ROAD <br /> Ll Owned VILLAGE: StJ)SS L N5/gAnJVYL - <br /> ❑ Public 1 or 2 Fam. Dwelling—#of bedrooms PARCELTAX NUMBERS) <br /> III. BUILDING USE: (If building type is public,check all that apply) ,3L —5 �-- y— 7�/ QQ/q00 <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 ❑ 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. 14 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 N Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 El 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 DAI 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC. RATE 6 SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(! q.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> q5V 3 1 (pl'$ - 1 5 • Feet V. S Feet <br /> VII. TANK CAPACITY Site <br /> in 11 ns Total #of Prefab. Fiber- App. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name ConcreteCon- Steel glass Plastic App <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank OOO <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 attachedplans. <br /> Plumber's Name(Print): Plumber's Signature:(No S mps) MP/MPRSW No.: Business Phone Number: <br /> ,cr}13 no /A�s fAG�wd IS 66- lS7 <br /> Plumber's Address( treat,City,State,Zip Code): <br /> Z'7700 0 ss 6/9651r-r' W/. V V <br /> IX., COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date ssue Ise Ing ent Sig ature(No Stamps) <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial I C� F�7-1 7-,"7 <br /> 7 ,Q 7 <br /> Adverse Determination �lJ �''lJ r J <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safely&Buildings Division,0 ner,Plumber <br />