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• . '410.0..0 SANITARY PERMIT APPLICATION <br /> at:L•■�+ COUNTY <br /> '��-�� In accord with ILHR 83.05,Wis. Adm. Code <br /> STAT SANITARY PERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than <br /> )&64; ' c)— (y•3,-.,6 <br /> 8Y2 x 11 inches in size. I I Check if revision to previous apication <br /> —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> eVill-L-t.\n �Oir v ,t gi Ya ., v31/4, S 15. T `, N, R /* ) W <br /> PROPER S MAI N A[99 ESS t LOT# BLOCK# <br /> .?7 '3T C-12 �•'7J <br /> CITY STATE IP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> IA); 69ä / ( )6,3C411/z- ,,no/G C,, tla. 124- t . <br /> II. YPE OF BUILDING: (Check one) ❑ CITY NEAREST ROAD <br /> State Owned TOWN OF l SK 0a r/2d- <br /> Public Al or 2 Fam. Dwelling—#of bedrooms PARCEL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) (, e/— 3//_O '" 3c <br /> 1 C. Apt/Condo `!" <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 U Outdoor Recreational Facility <br /> 3 n Campground 7 Merchandise: Sales/Repairs 11 I I Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 n 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. X New 2. Replacement 3. Replacement of 4. I I Reconnection of 5. Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) I I 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 n Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 Seepage Trench 22 In-Ground 42 ❑ Pit Privy <br /> 13 U Seepage Pit Pressure 43 _ Vault Privy <br /> 14 n System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1. ALLONS P R DIN 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> �ere.cCS REQUIRED, (sq.ft.) PROPOSED/Q (sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> b 4 13 6VS , 7 r/1oyA . '96:8 Feet 97 8 Feet <br /> VII. TANK CAPACITYin gallons Total ##of Prefab. Site Fiber- Exper. <br /> INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App. <br /> Tanks Tanks `,��, y structed (� <br /> Septic Tank or Holding Tank �,+1�/YCY L _ <br /> Lift Pump Tank/Siphon Chamber LI 0 El El LJ <br /> El <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,tar>K responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber'sSEP iI:EXCAVATION umber' Signator No Stamps) 400P7MPRSW No.: Business Phone Number: <br /> APA <br /> 59, Box 478d1712.'1-'- 33 3 ( ) <br /> Plumber's Aid 7 5)6,1=5-7482 1p Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary ermit Fee(Includes Groundwater Date Issued Issuin ent Sig lure I o Stamps) <br /> Tiers <br /> Fee) \ <br /> Approved ❑ Owner Given Initial ��Z% t 6-\ _ � <br /> Adverse Determination `/ , \J {{�� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08193) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />