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, ,�,�; ;r, SANITARY PERMIT APPLICATION <br /> v��-ttr■t� In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> , yam, cl q-ossl <br /> STATE SANITARY PERMIT U <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than -1. )(D 3 <br /> 8%x 11 inches in size. <br /> 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. /3 q7 rah?-10 <br /> PROP RTY OWNER M PROPERTY LOCATION <br /> QqOOS <12; t-,.�oso..S � '/a f '/a, S t T e l, N, R /2 eor) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> COlcX.n-,hty/ trA ,557 ( Y/V) 62 ' <br /> II. TYPE OF BUILDING: (Check one) ❑ CITY NEAREST ROAD <br /> ( ) ❑State Owned El VILLAGE: ✓- <br /> 4 <br /> ® TOWN OF c �C A.S -er <br /> ❑ Public 31 or 2 Fam.Dwelling—#of bedrooms. PARCEL TAX NUMBER(S) P <br /> III. BUILDING USE: (If building type is public,check all that apply) �s ' o ?/Z - d / 5 — 73/a ? <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 one in line A. Check line B if applicable) <br /> A) 1. l <br /> New 2. ❑ Replacement 3. I 1 Replacement of 4. ❑ Reconnection of R $$ fan <br /> System System Tank Only Existing System ystem <br /> B) ❑ A Sanitary Permit was previously issued. Permit# Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> SEP 2 b 1994 <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Dane CourAshinvironmental <br /> Health rri� <br /> 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 4T"�� RR, Tnk <br /> 12 N Seepage Trench 22 El 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 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./inch) $'�3 vL-EVATION <br /> b O 0 10,0 0 I O S • `E' —2_5. S`I <br /> CAPACITY Feet 4j , Feet <br /> VII. TANK in gallons Total /#of Prefab. Site Fiber- 41- <br /> Exper. <br /> INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App. <br /> Tanks Tanks structed <br /> Se ti oldin Tank 01 ZUb K "(Jy1 <br /> nk/Siphon Chamber 'R6 6 Sco ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plum Name(Print): Plumbe ' gnatur (N mp MPRSW No.: Business Phone Number: <br /> Plumber's ddress(Street, ity,Stale ip Code): <br /> A10 �, ( a)tUy4✓1 s3 'z <br /> IX. COUNTY/DEPA ME KT USEcINLY / <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Is -nt• • •Stamps) <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial ; dsari /y `'/ . 1�/;� <br /> Adverse Determination C( l /f . <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 0 <br />