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�Xf i`R �Y1 05) . <br /> SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couNrr <br /> iulor <br /> STA N RY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than (�3C(.sgq <br /> 8'%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 /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> /A jJ " L $0 ' �/4 /JE1/4, S Q T �� , N,IR 16 E (o <br /> PROPERTY OWNER'S MAILING ADDRESS LOT#L <br /> # <br /> 500 yjqR f4MOu 1. - 14 <br /> CITY,STATEZIP CODE PHONE NUMBER <br /> us so s-7 IOL+ cismt;5- io (715 v�ALJ 11s <br /> II. TYPE OF BUILDING: (Check one) ❑State Owned CIN .1 NEAREST ROAD <br /> 2 VILLAGE 'Ct rrND Q C <br /> ❑ a. <br /> Public 1 or 2 Fam. Dwelling-#of bedrooms`3 A CEL TAX UMBER(b) <br /> Ill. BUILDING USE: (If building type is public,check all that apply)'-' <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Out oor Recreational Facility <br /> 3 El Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Res aurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Oth r: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of I 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, <br /> AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED AREA <br /> ft.) PROPOSEED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> So l `43 � p ` 4.6- I Feet 97. 6 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exner. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Hold in Tank 000 00 <br /> Lif[Pum TanWSi hon Chamber <br /> Vlll. 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 Signature:(4Z= <br /> MP/MPRSW No.: Business Phone Number: <br /> I RD 0f to wG d 34Z6 <br /> Plu ber's Address(Street,City,State,Zip Code <br /> Z7 D w 3 7 Wge r" <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(includes_ Groundwater e ssu� Issuing A Signat r ( S ps <br /> Approved ❑ Owner Given Initial -',1,{'}�1-• Nf S�WII•afy�e', Is <br /> Adverse Determination \NNS <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SANT {� rrt iT t_:X ► 10-1 q <br /> SBD-6398(R.Oa/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />