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N <br /> SANITARY PERMIT APPLICATION <br /> V•�LffR <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> —Attach complete plans(to the county CO STATE SANITARY PERMIT# <br /> 814 x 11 inches•in size. PY only)for the system,on paper not less than .2D 7��� <br /> —See reverse side for instructions for completing this application. ❑ Check if revision to previous application <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. STATE PLAN I.D.NUMBER <br /> PROPERTY OWNER PROPERTY LOCATION <br /> a',Zh rr Y' 44/V:C= TAD-y,sCA/ /4✓'/i, .s'‘;1 '/a, S 3'/ T P , N, R� E(or)W <br /> PROPERTY OWNER'S MAILING ADDPESS LOT# I BLOCK# <br /> E go/ C;-ePaJ,t? j� el- i..oi S! <br /> CITY,STATE y ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> i#pAe7�LAt u'; �.5�3,o 1 i( 2J1 at <br /> ss- ,b,d��.q.0e.b ' ifs <br /> II. TYPE OF BUILDING: (Check one) ❑State Owned ❑ CITY NEAREST ROAD <br /> ❑ VILLAGE:S <br /> ❑ Public 1 or 2 Fam. Dwellin 0 TOWN OF Pr-Nff,P� P/r/ ,y•vz -40 t L L e.y el) <br /> g—#of bedroom PARCEL TAX NUMBER(S) <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 ❑ 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 in line <br /> Y one A. Check line B if applicable) <br /> A) 1. IR 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) cc <br /> Non-Pressurized Distribution Pressurized Distribution Experimental c��,��� Other <br /> 11 ❑ Seepage Bed 21 ❑ Mound / " <br /> 30 Li Specify Type $0� 41 ❑ Holding Tank <br /> 12 ] Seepage Trench 22 ❑ In-Ground q 4 <br /> 13 CI Seepage Pit Pressure n` [` 42 CI Pit Privy <br /> C hect/t my Ef,v r 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill (3) .- ( x ( SEC/A� -7- <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> ht � <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV., 7. FINAL GRADE <br /> 7671 REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) T,-is i = 1";i ELEVATION <br /> /5-11V 7504 0,_S— . 4, .t_= I//.?_ <br /> CAPACITY e a 3 '/k eet .47 Feet <br /> VII. TANK in gallons Total Site <br /> INFORMATION # k Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> New Existing Gallons Tanks Concrete glass A <br /> Tanks Tanks structed App. <br /> Septic Tank oAae{iing- aMc i .SZ° — A5b / <br /> lie,*o Gz, _ C— T ❑ i ❑ ri <br /> Lift Pump Tank/Siphon Chamber ❑ Cl r ❑ ❑ i — ❑ <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 /> i 4 L f/� a i- --yf-- etii-, f. y.,� .5 '. ( .(0-1 1 7) ..c-S'7 <br /> Plumber's AddreK Street,City,State,Zip Code): <br /> 2 o to f//� Ae2_ (Zik) . <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing A nt Signature(No Stamps) <br /> .p-Approved 0 Owner Given Initial surcharge Fee) <br /> /// �—(Al 10-,its-9y � /� ( ( /Yv� <br /> Adverse Determination ` <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County.One Copy To:Safety&Buildings Division,Owner,Plumber <br />