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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code c uNTv <br /> S E NI RY P RMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than � L�y ���s�3 <br /> 8%X 11 Inches In size. Check if revision to previous application <br /> —See reverse side for instructions for Completing this application. S rATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION '1 <br /> bgace N E '/a '/a, S 7i1 T X10 14, 11 15 E(or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BL CK# I <br /> Z?Z? DPE Ro <br /> CITY,STATE ZIPCODE PHONENUMBER SUBDIVI IONNAMEORGSNlll <br /> S,551-eg gwrl I813 - 1 c S <br /> El CITY NE REST ROAD <br /> II. TYPE OF BUILDING: (Check one) ❑State Owned VILLAGE.�f;C ILSOi� O�G JZD <br /> ❑ Public �1 or 2 Fam. Dwelling-#of bedrooms-1- PA EL A\\X NUMBER(S) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) (�`O' er- C, VO <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 ❑ S rvice Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ ther: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. K 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 DAI 2.ABSORP.AREA 13.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 /> 95D (D43 6.50 � -- 47-1 Feet -IpS S Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Expp. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concret Con- Steel glass Plastic App <br /> Tanks Tanks <br /> struct <br /> Septic Tank or Holdino Tank Milo0 <br /> Lift Pump Tank/Si hon Chamber <br /> El H <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 Stamps) MP/MPRSW No.: Business Phone Number: <br /> 'KIL AKo 00priNs g autj3y2� l5 66Ills, <br /> Plumber's Address Street.City,State,zip Codd): <br /> wmo Hw wmg <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater ate ssue Issuin Agen�Sign tur (No tamps) <br /> PK <br /> Sur�parge Fee) / r <br /> IYI'x'\Approved ❑ Owner Given Initial r'l/.YCIJcN <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SB66398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division, writer,Plumber <br />