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■ <br /> Iii5iR SANITARY PERMIT APPLICATION <br /> ��,�„•e. � In accord with ILHR 83.05,Wis.Adm.Code COON <br /> STATE SANITARY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than /‘,6/471-175- <br /> 834 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. <br /> PROP h'OWNER c PROPERTY L ATION <br /> i <br /> S o 1�.Lks e I ( /Yt.y./v '/•,S 3 T 7 , N, R 8 E(or)2C. <br /> PROORTY OW E ,15145A/A14 AILING ADDRESS—F., OT# BLOCK# <br /> A3 13 ciz'Ve o� <br /> CITE/ TA,T ZIP CODE PHONE NUMBER SU lVISION•NAME OR CSM NUMBER <br /> /!�i` ) / /,d 356.2 ( ) /46 7 <br /> II. TYPE OF BUILDING: (Check one) • D CITY NEAR ROAD <br /> ❑State Owned .C11TYA71 / /Z! , I )w� j_ C j�r' <br /> ❑ Public 1 or 2 Fam.Dwelling-#of bedroomt�� ��L 7,4�(NI ER( �[ d$ <br /> III. BUILDING USE: (If building type is public,check all that apply) /a_D �e ` 03/ - !t0 b -.-Z 1 ❑Apt/Condo il, ` 7 <br /> 2 El Assembly Hall /�� 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 1 V 7 ❑ Merchandise: Sales/Repairs 11 El Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ 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.XNew 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) FCrA <br /> Non-Pressurized Distribution Pressurized Distribution Experimental O /4`4,.gther 4© <br /> 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 4he 1,B, olding Tank <br /> 12 �4 Seepage Trench 22 ❑ In-Ground yec(3 42 •f'••i ivy <br /> . i <br /> 13 • Seepage Pit Pressure Os44 , Vault Privy <br /> 14 ❑ System-In-Fill �s "Yir <br /> Y potF �� <br /> VI. ABSORPTION SYSTEM INFORMATION: 4f rC/ <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) aQ C� ELEVATII N <br /> 1 <br /> A",,i" 7 5 ) — 75?) , - - 7 /V / Feet G3..a Feet <br /> VII. TANK CAPACITY Site <br /> INFORMATION Con- Steel in gallons Total #of Manufacturer's Name Prefab. Fiber- Plastic Exper. <br /> New Existing Gallons Tanks Concrete structed glass App. <br /> Tanks Tanks <br /> Septic Tan Holding Tank 4256 � 44.4._ l a El J1 a <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ El El El ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installati• of the onsite sews•_ - stem shown on the attached plans. <br /> Plumber's Name(Print: k Plu •'' ''• ature( S :m / /MPRSW No.: Business Phone Number: <br /> Al.... " A �6 c 'r- - =�/ -4 i��s 5 •. -8/o3 <br /> P um r'sAddress "le=t,City, te,Zip ••e: � ���� <br /> ii <br /> 66 7 , 6 l�_1a,�/yc.k�e 7- <br /> IX. COUNTY/DEPA'TMENT USE 0 LY <br /> prA ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e Issued ssuing Agent Signature(No Sta s) <br /> pproved 1 Surcharge Fee) <br /> ❑ Owner Given Initial L ''� IQ /Adverse Determination I <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly PIb-67)(R.11/88) ' DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />