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6 SANITARY PERMIT APPLICATION <br /> v��nIR In accord with ILHR 83.05,Wis.Adm.Code cou TY <br /> STA SANITAqRY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than I�'3 G1) 3353 ) <br /> 8'h x 11 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. ON <br /> PROPERTY OWNER LPROPERTY LOCATION <br /> '/a t/a, S T N, E (or) <br /> PROPERTY OW ds MAILING ADDRESS BLOC # <br /> Z 239 EI-" RD _ 25 4-CITY,STATE ZIP CODE PHONE NUMBER VISION NAME OR CSM NUMBER <br /> E3 W( . 8rt3 6. 8 � S Q " 7II. TYPE OF BUILDING: (Check one) Y 1n�t NEAREST ROAD <br /> State Owned VILLAGE oA� rll D <br /> ❑ <br /> Public 1 or 2 Fam. Dwelling {hof bedrooms 3 ARCELTAXNUMBER( ) <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 ❑ Res aurant/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. TYII��P-JEII OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. LNew 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 /> 11Seepage Bed 21 ❑ Mound 30 ElSpecify Type 41 ❑ Holding Tank <br /> 12 N 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 37 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADINGRATE 5. PERC. RATE 6. M EV. 7. FINAL GRADE <br /> �� REQUIRED(sq.ft.) PROP,IOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 94 -S <br /> ELEVATION <br /> 3 �oY'$ •7 `—' •lD set 1 4 - o Feet <br /> VICAPACITY I. TANK in gallons Total #of Prefab. Cc a Fiber- Exper. <br /> INFORMATION New istin struGallons Tanks Manufacturer's Name Concrete rutted el glass Plastic App <br /> Tanks Tanks <br /> Septic Tank orHoldin Tank (DOO DOO <br /> Lift Pump Tank/Siphon 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 Stamps) MP/MPRSW No.: Business Phone Numbs <br /> u1 lo P lt/% 3 126 IS 866 rI: <br /> S <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 27760 HW .36 \468srm wi •.S`fsa3 <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee includes Groundwater ae ssue Issuin Ag t5ignat r (No 11 mps) <br /> �pproved ❑ Owner Given Initial I �ur gree Fee) <br /> Adverse Determination i <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.0893) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Ow er,Plumber <br />