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� Cam <br /> SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code c I,1 <br /> ST NTE SANIT RV PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less thanG`�a >L( �— <br /> 6'%x 11 inches in size. Chack if r ision to previous hip'pl_ic'ation C <br /> -See reverse side for instructions for completing this application. Sr kTE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> '/a Ya,S T T �,, N R 6 E (or W <br /> P OPERTY OWNER'S MAII., ADDRE LOT# 1 BLO K# �) <br /> CITY,SiATE�J, 21P CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> s )a <br /> ss 6 <br /> 11. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLLLAGE �; NEA EST RT <br /> ❑ Public 91 or Fern. Dwelling-#of bedrooms C PAR EL AXNUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) O _ <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Ou door Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Set vice Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYl PSE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. LJ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) 19 A Sanitary Permit was previously issued. Permit# 1_ki\`i�6 Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 L✓� 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.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REO�88Q11RED(sq.ft.) PROPQSED(sq.ft.) (Gals/,day/sq.ft.) (Min./inch) 'I�`C ELEVATION <br /> L�Y.J, \ Feet I p Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xistin Gallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon Chamber 3b <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumbed s Name(Print): Plu 9i nature:(No mps MP/MPRSW NIL Business Phone Number: <br /> \\ GS 3�(� g66 yam? <br /> Plumber's Adess(Street�C(ily,State, <br /> ^ Y J l <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing g t Signa u e o,SI mps) <br /> Approved ❑ Owner Given Initial1t surc-hgkge Fee) <br /> Adverse Determination __AN W I /_ �Al/I <br /> X. CONDITIONS APPROVAL/REASONS�aa FOR <br /> P orA91 oal I Cc'ST. � �vtpii/ 1. <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Ow er,Plumber <br />