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SANITARY PERMIT APPLICATION <br /> 0i„LtI.AR In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STAT <br /> E�SANIT ERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than CC1ldd JJ\\ ,W1 <br /> 8'h x 11 inches in size. ❑ Check if revision 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 /> PROPER NER PROPERTY LOCATION <br /> (2 t SW%a S Ea, S Z 7 T 3 d, N, R /g or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT # <br /> z/93l- S 2r^ .CislCe )2�1 cJ �a✓ Loi- � ;'� 3 <br /> CITY,STATE ' / ZIPCODE PHONE NUMBER SUBDIVISION NAM OR CSM NUMBER <br /> iXiae,01 W`S4r>wy l-i I.fytf 7 /S 32 - 6 CS r 1 v� ?I <br /> CITY <br /> If. TYPE OF BUILDING• (Check one) ❑ State Owned O VILLAGE - NEAREST ROAD <br /> ❑ Public or 2 Fam. Dwelling-#of bedrooms 7' AR EL TAX NUM BER(s) <br /> III. BUILDING U : (It building type is public,check all that apply) 04 <br /> 1 ❑ Apt/Condo Vv UUU <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. TYPPE�OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1 ew 2. ❑ Replacement 3. El 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 El 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 7 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 /> 3� yZ0 4 �03 '3 L�/Orr Feet Ofi Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New xistin Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank atm /V" i <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): Plumber's Sin :(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> QI1G2 r3vlr! moa <br /> Plumber's Address(Street,City,State,Zip Code):— <br /> /.7!/ A .m/cG / e.r Gr/i 5 f 7 2- <br /> IX. <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includea Groundwater Date IssuedIssui ent Sig re(No Stamps) <br /> ®.Approved ❑ Owner Given Initial tf' ���r.�,charge Fee) 4 <br /> Adverse 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 />