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Jun. 2. 2009 8:54AM No. 0606 P. 3 <br /> ''tea., SANITARY PERMIT APPLICATION <br /> (piiiR COUNTY n <br /> In accord with ILHR 83.05,Wis.Adm.Code '7 S <br /> STATE SANITARY PERMIT# , rj <br /> --Attach complete plans(to the county copy only)for the system,on paper not less than /-;?-7//6 46 <br /> 8V x 11 inches In size. ❑Check If revision to previous application <br /> —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION, C. f}" -0/JJo <br /> PROPERTY OWNER _�..... W+� � ... PROPERTY LOCATION <br /> A/boil (;/•-/'cc; fA s 5l<, th sr.4" %,S 5" T 5' , N, R E(er-W '7 _PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> —l'/ .2 7 O1.P 5e-/-lees 02nnd1 1 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> in&ZO�nan f'e U). s$err (1e0g )767-M1 r� '7 3 77 <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> _ ❑State Owned I] VILLAGE � <br /> ('/ ere to 5 fr r,_S <br /> Li Public V.1 or 2 Fam. Dweliing-#of bedrooms.1 PAR E T• 1 I v=ER <br /> III. BUILDING USE: (If building type is public,check all that apply) a _ $. 3 _ a <br /> 1 ❑ Apt/Condo <br /> 2 LI Assembly Hall 6 ❑ Medical facility/Nursing Home 10 LI Outdoor Recreational Facility <br /> 3 ❑ Campground /1/ 7 El Merchandise: Sales/Repairs 11 1:1 Restaurant/Bar/Dining 4 ❑ Church/School i U / B ❑ Mobile Herne Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 U Other: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line IB If applicable) rr—�� <br /> A) 1.© New 2. 111 Replacement 3. ❑ Replacement of 4.u 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 /> j Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 ® Seepage Trench • 22 ❑ In-Ground 42 U Pit Privy <br /> 1 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 11.GALLONS PER DAY 2.ABSORP.AREA �3.ABSORP.AFFEA 4. LOADING RATE 5. PERC.RATE 6.SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft) PROPOSED(se.ft.) (Gals/day/sq.ft.) (Min./inch) 4 fe,0 q iii A ELEVATION <br /> FQ 0 C ~—• 5, Feet '/D Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber Plastic Exper. <br /> INFORMATION Now existing Gallons Tanks <br /> Tanks Tanks Concrete glass App. <br /> structed 77 <br /> Septic Tank or Holding Tank 2Y50 3q50 , a.. i /r°ad e I 1 [1 0 ._. <br /> Lilt Pump Tank/Siphon Chamber _ ,_ t_J -.1--- --- ---_ L:1 -_ — <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite se , e system shown on the attached plans. <br /> Plumber's Name(Print): Plu -r ign:tti ■. •10•- -• JO MP/MPRSW No.: Business Phone Number: <br /> t` - / CeosIP z gc <br /> . ',` 337 . (4o? ) y31 - w03 <br /> Plumber's Address(Street,City,Stat ,Zip.Co.d). , <br /> rA sc.7 , C re /1w s- (d.� „rd� s 3 s 7 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> 34, El Disapproved Sanitary Permit Fee(Inudea Groundwater "a e ss� °"rissui nt Signature(No Slam <br /> 9 charge Fee) <br /> pproved 0 Owner Given Initial [~j 8'1 5 <br /> Adverse Determination 7(„J ( �f/� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> ag¢B39g(R.oa/03) DISTRIBUTION: Original to County,One Copy To:Safely A Buildings Division,Owner,Plumber <br />