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-17 <br /> SANITARY PERMIT APPLICATION <br /> + 'r' <br /> �� IR In accord with ILHR 83.05,Wis.Adm. Code co�u�NTv <br /> S AT SANITAq\YPER\MIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than El�(&�-(yJ r73��I LI <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 /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER LPR�OPERTY LOCATION f <br /> E ''/s, S23 T I , N, RPROPERTY OWNER'S MAILING ADDRESS BLOCK# <br /> 3o7So 35CITY,STATE ZIPCODE PHONE NUMBER ON NAME OR CSM NUMBER <br /> 1?ANSutZ L1( . .9 83oII. TYPE OF BUILDING: (Check one) NEAREST ROAD <br /> State OWned GE�QWW OFI❑ Public ❑1 or 2 Fam. Dwelling-#of bedroomsAX NUMBER( ) J <br /> III. BUILDING USE: (If building type is public,check all that apply) S-2- 5323 '" 02 ,00 <br /> 1 ❑ ApVCondo <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. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4.mReconnection of 5.❑ Repair of an <br /> . System System Tank Only\ ` Existing System / Existing System <br /> B) A Sanitary Permit was previously issued. Permit# � 0 �C�lY Date Issued L�- n � I <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 A 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 ADDING /so 'f+t - +o E,41-s- i $En <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> // <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 17 . 16o <br /> '7 / ELEVATION <br /> 1 o o ss 00 / ! ( . b Feet 00• Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Hold!no Tank (ZSo ( Kq�j <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 plans. <br /> Plumber's Name(Print): Plumber's Signature,(No/SS lamp MP/MPPRSW No.: Business Phone Number: <br /> rcHgRb 019141✓S 71 i � 15 0-7' 05 <br /> Plumber's Address(Street,City,ptate,Zip Code): <br /> 277&o ltw3 W�BSfK W! • S ��3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee(Includes Groundwater Date lssued <br /> Issuing en ign tur o tam s) <br /> %Approved ❑ Owner Given Initial &rcharge Fee) <br /> �� _1 L <br /> Adverse Determination CTS IU <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(RA8/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />