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cn <br /> SANITARY PERMIT APPLICATION COUNTY <br /> E <br /> �L`A'�j` In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITARY PER IT <br /> aper not less than <br /> a� 71�7� <br /> –Attach complete plans(to the county copy only)for the system,on pEE] Check if revision to previous application <br /> 8%X 11 inches in size. STATE PLAN I.D.NUM d <br /> -See reverse side for instructions for completing this application. ALJ <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATIOo E TY O ATION <br /> PROPERTY OWNER C .dV tea S 17 . T 34, N, R IW <br /> :Sftwk— G70tJ.r'(3E. �E� BLOCK# <br /> PROPERTY OWNER'S MAILING ADDRESS G <br /> `+ <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 1jba a nnlla0.K 554`M tZ (pip-%47 NEAREST ROAD Q <br /> 11. TYPE OF UILDING: (Check one) F] State Owned ❑ VILLAGE: 1S� <br /> ❑ Public tZ 1 or 2 Fam. Dwelling–#of bedrooms Z PARCEL TAX NUMBER( ) <br /> III. BUILDING USE: (if building type is public,check all that apply) ::L _ 31%Z_ 64— t}00 <br /> 1 ❑ Apt/Condo10 E] outdoor Recreational Facility <br /> 2 El Assembly Hall 6 El Medical Facility/Nursing Home 11 ❑ Restaurant/Bar/Dining <br /> 3 El Campground 7 ❑ Merchandise: Sales/Repairs 12 ❑ Service Station/Car Wash <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park <br /> 5 ElHotel/Motel <br /> g ❑ off ice/Factory <br /> 13 ❑ Other: Specify—� <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. 0 New 2. r of an <br /> �Replacement 3. El Replacement of 4.[1 Reconnection ofExisting System 5 E] Existing System <br /> System System Tank Only <br /> B) ❑ A Sanitary Permit was previously issued. Permit# <br /> Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) Other <br /> Non-Pressurized Distribution Pressurized Distribution Experimental 41 ❑ Holding Tank <br /> t 21 ❑ Mound 30 F1 Specify Type 42 ❑ Pit Privy <br /> 11 D Seepage Bed Lt EJ 12 ❑ Seepage Trench 22 43 El Vault Privy <br /> 13 ❑ Seepage Pit Pressure <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: ELEVATION <br /> 1.GALLONS PER DAY 2.ABSORP.AREA PROPOSED AREA 4. L(GaAsD/day/sq.ft)ING RATE 5 (Min./inch)c h)E 6. SYSTEM ELEV. 7. FINAL GRAD <br /> REQUIRED(sq.ft.) d V% 4(o.4Feet q .+ Feet <br /> 00Site <br /> 4-2-el 't <br /> CAPACITY Prefab. Con- Steel Fiber- Plastic ExpP. <br /> VII. TANK in allons Total It of Manufacturer's Name Concrete glass App <br /> INFORMATION nGallons Tanks strutted <br /> Taks Tanks <br /> ►� 750 <br /> Se tic Tank Cjp 500 <br /> Lift Pum Tank' nbn <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,ass onsibility for installation of the on a sewage system shown on the attached plans.usiness Phone Number: <br /> MD/MPRSW No.: <br /> Plumber's NIL & EAVA 69 er's Si ature:(No S Ps) <br /> N6228 Cour Line Rd <br /> Plumber's Address ode): <br /> (715) 7482 <br /> IX. COUNTY/DEPARTMENT USE ONLY Issuing A ent 'gnatur (N a <br /> Disapproved Sanitary Permit Fee(includes Groundwater ate s e <br /> t Surcharge Fee) <br /> Approved ❑ Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS F S PPROVAL: <br /> SBD-6396(R.08/93) <br /> DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />