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SANITARY PERMIT APPLICATION <br /> �iLPrBTi In accord with ILHR 83.05,Wis.Adm.Code cou Tv <br /> STA E SANIT Y PERMCIT1 # <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than �� l ?`\K <br /> 8%x11 Inches In size. heck if revision to previous application <br /> —See reverse side for Instructions for completing this application. STA E PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. I ry <br /> PROPERTY OWNER PROPERTY LOCATION v I <br /> I,V/Jr1.9 .✓ e,^J SW'/4 /'/t"/4,S TS10 , N, S E (or)® <br /> PROPERTY OWNER'S MAILING ADDRESS LOTI 1 ' BLOCK# <br /> FA .33 e Lv/- /mac i17 <br /> CITY,STATE / ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> II. TYPE OF BUILDING: (Check one) Li CITY NEAREST ROAD p / <br /> ��ryry ❑ State Owned VILLAGE ' So 6 <br /> ❑ Public 01 or 2 Fam. Dwelling—#of bedroomssaL PAR LTAXNU4QWN QF- M t3LR(S) <br /> III. 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 ❑ 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 /> lck� <br /> A) 1. ❑ New 2. IL2f 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 D9 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 PERDAY 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 /> y5-6) 5 y� 6 e ( y 97 Feet 95 9 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> rZ <br /> Septic Tank or Holdino Tank JOBB 1 <br /> Lift Pum Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached lans. <br /> Plumber's Name(Print): Plumber's Signature:(No S ps) MP/MPRSW No.: Business Phone Number: <br /> �/y�l� /J 4/C3�ia�.rti vlu�✓ � � � C� � �i3 ��9'—�..?� <br /> Plumber's Address(Street,City,State,Zip Code): <br /> /,o c) /'e>! S/y Ste. --.,J w,z .3 y8J2 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ <br /> Disapproved Sanitary Permit Fee (includes Groundwater a e ssue Issuing i s a r (No mps) <br /> " ^^S,veTerge Fee) �`— <br /> Approved ❑ Owner Given Initial Per itt``e (inch✓ <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 />