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5114:114 SANITARY PERMIT APPLICATION <br /> COON <br /> In accord with ILHR 83.05,Wis.Adm.Code T 1 l e_9O_oa <br /> STATE# ARY PERMIT# <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than )4D,3(, <br /> 814 x 11 Inches in size. ❑Check if revision to previous application <br /> –See reverse side for instructions for completing this application. STATE PLAN 1.0.NUMBER <br /> I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. S9O-00935 <br /> PR OWNER PROPERTY LOCATION <br /> d{ t Su) yo .IA,S / 7 T ,N,R -7 E(or)� <br /> PROPARTY QWNER'S fILI n: LOT# BLOCK# <br /> CITY,STATE {a��i !Y'ZZIIPP CODE PHONE NUMBER : BDIVISION NAME OR CSM N <br /> cleos�t 4ete r[s 535o?Y_( ) . <br /> 11. TYPE OF BUILDIN r• (Check one) ❑State Ow( _ ITY NEARES ROAD <br /> ILLAGE: <br /> ❑ Public 1 or 2 Fam.Dwelling-'#of be• •oms - v `1' : <br /> III. BUILDING USE: (If building type Is public,check all hat apply) /11/4 <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall t 1 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground ‘N 7 ❑ Merchandise: Sales/Repairs 11 El Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 El Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 El Other: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1.KNew 2. El Replacement 3. CI Replacement of 4.11 Reconnection of 5.CI Repair of an <br /> System System Tank Only Existing System t1� Existing System <br /> B) CI A Sanitary Permit was previously issued. Permit# — Dail , <br /> issued <br /> r, <br /> V. TYPE OF SYSTEM: (Check only one) n, 7 4 <br /> Non-Pressurized Distribution Pressurized Distribution Experimental yG &� `a r <br /> f <br /> 11 ❑ Seepage Bed 21(gMound 30 ❑ Specify Type ' , <% 41 Ce/Holding Tank <br /> 12 ❑ Seepage Trench 22 In-Ground `OA �% 2 Pit Privy r_i <br /> 13 ❑ Seepage Pit Pressure .9..� Vault Privy <br /> 14 ❑ System-In-Fill e7jr el44i <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.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./In ELEVATION <br /> S75- 3'7� /, Z o2 X /0 3,z Feet � 5- Zfeet <br /> VII. TANK CAPACITY Site <br /> N <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic <br /> lass Exper. <br /> New Existing Gallons Tanks Concrete structed g App. <br /> Tanks Tanks hon / _ _ _ _ <br /> T1>•I Tank /000 eade `� — c <br /> .,.hon Chamber aer gfri i ( vit — — — — <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for Instailation,of onslte sewage ystem shown on the attached plans. <br /> Plumber's Name(Prin Cee) Plum s e:(No�9te ISSVMPRSW No.: Business Phone Number:� l I 337.S I ((od&)831- k <br /> Plu ' Address(Street,City,Sta ,Zip e)� v <br /> I�NTY/DE114tTM T U ONLY <br /> A#4# . s3s97 <br /> EJ Disapproved Sanitary Permit Fee(Includes a Fee)Groundwater •a a ssue• setting Sign a(No e) <br /> Approved ❑ Owner Given Initial <br /> Surcharge Fee) 5�S- l <br /> Adverse Determination_ $41-1-b t I <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8388(formerly PIb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />