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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code c UNTY <br /> -Attach complete plans to the count co only)for the system,on paper not less than STT SANITARY PERMIT# <br /> P P ( Y PY Y) Y P P �S <br /> 814 x 11 inches in size. J <br /> wChk If revision to previous applicationec <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 OWNER PROPERTY LOCATION <br /> �IC)« vvB Y�<I��iL/��ZS N/J ^/s SQL/'/., S TY") , NR / E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOC <br /> LO K# <br /> 7831 Glt�11�'Ct /Zv. SG�� 'tc <br /> CITY,STATE STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Sea <-/z P41q <br /> 11. TYPE OF BUILDING: (Check one) ❑State Owned CIN NEAR EST ROAD <br /> VILLAGE ��� <br /> ❑ Public X1 or 2 Fam. Dwelling <br /> g-#ofbedroom� AR ELTA/XNUM ER( ) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) h_ `C1 \ <br /> 1 ❑ Apt/Condo v C7 .1 <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. DKReplacement 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) ELEVATION <br /> ( C� / it <br /> r�s b r 7 ' Feet Feet <br /> VII. TANK CAPACITY <br /> in alions Total of Prefab. Site Fiber- <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- test glass Plastic Aper. <br /> Tanks Tanks structed pp. <br /> Septic Tank or Holding Tank 1 /250- 1 !i/L7-46A2 <br /> Lift Pump Tank/Sipon Chamber ;tz 7� <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached pie ns. <br /> Plumber's Name(Printf: Plumb Signature:(No Ste MP/MPRSW No.: Business Phone Number: <br /> r__ ., T 2y�3sltr <br /> Plumber's Address(Street,City,State,Zip Codef: <br /> 16 ?/ <br /> IX. COUNTY_/_DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater as as ad Issuin g Si n t re Stamps) <br /> �pproved ❑ Owner Given Initial -'1}�,Y r arge Feel <br /> AdverseDetermination 111--��� " ' <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Own <br /> e ,Plumber <br />