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SANITARY PERMIT APPLICATION <br /> �•���� In accord with ILHR 83.05,Wis. Adm. Code COUNTY <br /> STA E SANIT Y PERMIT## <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8h x 11 inches in size. �� <br /> Check if re Sion 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 /> PROPERTY OWNER / PROPERTY LOCATION <br /> ./ -eo� gl- r-,ST10-41Se,*1 AW % SP6 '/4, S /V T3S, N, R �r) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT## BLOCK## <br /> Zw-"F ,� � <br /> CITY,STATE ZIP COD PHONE NUMBER SUBDIVISI N NAME OR CSM NUMBER <br /> 11. PE OF BUILDING: (Check one) State Owned CITY O VILLAGE NEAREST ROAD <br /> TOWN OF7 <br /> ❑ Public Z 1 or 2 Fam. Dwelling-##of bedrooms Z PARCEL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) C4 y- ' 1 L, C4 -9(y) <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 /> A) 1.19 New 2. ❑ 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 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.ASSORP.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 /> 300 j4;Zy 3 Z- . 7 /rlo.- L, q'4&Feet Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in aallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App. <br /> Tanks Tanks structed <br /> Septic Tank 00 00 / <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation oft onsite sewage system shown on the attached plans. <br /> -j ' <br /> Plumber's Name(Print): PI tuber's Signature: o Stamps) VE/MPRSW No.: Business Phone Number: <br /> i.cTeg bon% 3353 ,S l035-- 87— <br /> Plumb is Address( eet,City,State,Zip Code): <br /> RCflL S ox `1-78 A o0iney <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> 7( ❑ Disapproved Sanitary Permit Fee(Includes Groundwater ate IssuedIssuing a Signature No tamppy <br /> I!N A roved Surcharge Fee) _ <br /> 'T` pp ❑ Owner Given Initial � � [\ I <br /> Adverse Determination /_ ��h j �1 <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 />