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• <br /> D SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> .d..,,....,,, 1 PA W� W- 0 $7 9 <br /> -Attach complete plans(to the county CO STATE SANITARY PERMIT# <br /> P P ( ty py only)for the system,on paper not less than / °/(pal <br /> 8%x 11 inches in size. <br /> ❑Check if revision to previous application <br /> -See reverse side for instructions for completing this application. <br /> STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OW R I � s- PROPERTY LOCATION <br /> bOr� i nelOn t 4-Driv NEB.Ntnl%, S S T 7, N, R // E (oV <br /> PROL-ecc WRo y i ANY LOT# 7 BLOCK# <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> NINAr)ISO0� L�( S �]j 3,(�o� ) �3 Zl C_ t /<.va 4-1""S <br /> II. TYPE OF BUILDING: (Check one) ❑State Owned p0 VILLAGE' r.r I NEAREST ROAD <br /> ® TOWN OF: la2�t/'. frOLL/YJ 0/L,E 1V/54' <br /> ❑ Public 1 or 2 Fam.Dwelling#of bedrooms`. PARCEL TAX NUMBER(g) <br /> III. BUILDING USE: (If building type is public,check all that apply) ©' 37/; _ 0 5� /50 7 - cs <br /> 1 ❑ Apt/Condo ! C J / <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. New 2. ❑Replacement 3. ❑Replacement of 4. ❑ ReconneJion of O 5. air of an <br /> System System Tank Only Existing S�1f m �` Aig System <br /> B) ❑ A Sanitary Permit was previously issued. Permit# — Date Iigd,, C� , � ;) <br /> V. TYPE OF SYSTEM: (Check only one) 4'x: '� %y,, <br /> y <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 t3,Holding Tank <br /> 12 Seepage Trench 22 CI In-Ground 42 ID Pit,,Privy <br /> 13 Seepage Pit s Pressure 43 III Vault Privy <br /> 14 ❑ system-In-Fill ?) S' / .5&-PA-6-e_ 7-/ Ery c77f <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 /> ��O REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft) (Min./inch) 7 92 Y ELEVATION <br /> 00 900 S27 /Ufa 7:2 X17.0 /co.0 Tv <br /> CAPACITY T 3 7‘ 1 Feet / 1 S' Feet <br /> VII. TANK in gallons Total Site <br /> Prefab. Fiber- Exper. <br /> INFORMATION New Existing Gallons Tanks Manufacturer's Name oncret: Con- Steel Plastic <br /> Tanks Tanks structed glass App. <br /> (Septic kJbfHefdinq-T-enk /oov 000 / /k7 . i n fl El <br /> Lift Pump Tank/Siphon Chamber ❑ El ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> PI m is Name(Print): Plu 's Signature:SlVo a ps) . P/MPRSW No.: Business Phone Number: <br /> 1Nt S. f e � � .;.�-7-.e_ ...d. 7-,�A-�.� .� ,i 6C,,Y Z2/—� 7/ <br /> s <br /> Plumber's Address(Street,City,State,Zip Code): <br /> ( ) <br /> 7/eY M/'% 2Af ,S F. M/7/-0/3O,// /4//,f_ S3"7/3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing ent Signature(No Stamps) <br /> {�A Surcharge Fee) ,� <br /> Y pproved Owner Given Initial ^� �, v �// <br /> Adverse Determination �'�`C'-- �`/ O?/�a, :ALL ��t� ���� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: -/ <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />