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AS BUII,T SANTTARY AY6TEM REPORT
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PI,AII VIEW
SHOW EVERYTHING WITI{Iil 1OO FEET OF SYSTEI{
tri,'ii)E.r.I.;.a I
€r!- adaouA Ptof
Plt "t
ORIGINAL
TNOTCEIE NOBTH ARROI{
Provide setback and erevation infornation on reverse of this fonn'
Provide 2 dinensions to center of septic tank manhole cover'
A
St
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r;{)r,-P 4 Puav ^'toRa<7'frp of- /' 7/ eLTt Ay esfLt i7' caFzEP
Af Fe-uce /t:uES - €/Eu+zat - /OO.O '
BENC HMARK:
AI,TERNATE BM:
BH +tL oPs tC TAlJk - Bo'ttox 6
a
g/occo
oo,o
sEPUc TANK ,/ PUMP CIIAI{BER ,/ EoLDING..TANK INToRM}IIoN &l- 1c?Ic T
Manufacturer:b*5 Otaz/< 6 . Liquid capacity:?oo 'P c.
iflfic f'setback fron:w.i-l /33' HorJ" 2r/' other
PuDp: Manufacture , /q€//EP'24U'uoae:^|. *sLz" )/z l*
Froat sepera tion-? L'
-
callonslcycte:/r,
AIaLT Location y'ttsr?€ r/b,q{
'160II., ASGORPIION SXETEII
^,flidttl: (6r/'Nunber of tre
P
Distan'ce & Direction to nearest prop. Iine:/o6 ?4 oE6 T
setback froE: well >5oo Hcitse> Sod' o*",
E&E\IATIONS.L
floa Buirding s"r"r-?Z'35 _ sr rnretr
Pc inr'er /o('ro'
An#b Pt.tE sr outret ??' OS
Pc botton /a/ Ce'Punp off /o5,?o'
Header/Manifold //.lo Bottom of systen
sEPr /ff/
h P RS 330-7
Pf24 B/4
ff///o. ra'
lirK{ er^a" /of'fu pinaL srade aa? of lou.tD //2 -€a
aa& lrou^rD tr'
,*lo.'r'nuHffio*,
PII'MBER ON JOB:
LICENSE NUMBER:
PoB€ti- ?,(LBRr'chj-
INSPEeTOR:
3/93 t)x
MA?U Jeo kros
-
ItE,TLHFI
I-ffi-t-EEffi;a.-___l
-
SANITARY PERMIT APPLICATION
ln accord with ILHR &3.05, Wls. Adm. Code
-Attach-c.om.plete plane ((o the county copy olly) lor the eystem, on papsr not less than
814x11 lnches ln slze.
-See reverso slde lor lnstructione for completlng thls appllcatlon.
I. APPLICA]IT IilFORUATIO}I - PLEASE PRIIIT ALL IIIFORIIATIOIII.
57.c/fuY'1
STATE
It appllcatlon
'7
PROPERW OWNEB'n"ffifffn Ia^t W'i,W^;iito r2l,N,R /3 eo@PR,PY ER'' MA*rNt fr)Yilrztr< I T'LOT#a-BLOCK #
-"il'uW fult 4t,zrPcooE
Sqotu-
PHONE NUMBEReLSt?{t?SIJBDIVISION NAME OR/+tr 6F *yA"E ieq,
[.TYPE p/z,ttt'NEARESTROAD tlar?State Owned ,t
oearooms{
Qur+tQtrilng+ol
lll. BUILDING USE: (ll bulldlng typ€ lt public, check atlthat apply)o>L-toP?-Coooa
r fJ Aoucondo
z fJ Assemblv Halt
3 fJ Campground
+ lJ Church/School
s fJ Hotet/Motet
6
7
I
9
Medlcal Faclllty/Nurslng Home
Merchandlse: Sales/Repalrs
Mobile Home Park
Ollce/Factory
10
11
12
13
Outdoor Recreatlonal Facl I ltY
RestauranUBar/Dlnlng
Servlce Statlon/Car Wash
Other: Speclty
IIII
N. TYPE OF'ER
A)1.ffi*-
Syi-tem
lllT: (Check only one ln llne A. Check llne B ll applicable)
e. E Reptacernent g. E Replacoment olSystem Tank Only
4.Reconnectlon of
Exlstlng System
s. E Repalr ol an
Exlsting System
B) E e Sanitary Permlt was prevlously lssuod. Permlt #
Y. TYPE OF SYSTEI|: (Check only one)
Non-Pressu rized Dletributlon P ress u r i zed^D istri b uti o n
21 6tnon J tn€round
Experimental
SO E Specify Type
Olher
11 Seepage Bed
Seepage Trench
Seepage Plt
System-lrrFlll
41
42
{}
Holdlng Tank
Plt Prlvy
Vault Prlvy
12
13 Pressure
14
VI. ABSORPTIOil SYSTEH INFORIIATION:
2. ABsoRp. AREA lg. eBsonp. AREA ln. roaotxo nere I
W,Z.r
(sq n ) WfD (sq nl
l, :'-do"r,* r
I
5. PERC. RATE
(Min./lnch)
rUrq
O. SYSTEM ELEV.
ho,f Fect
7. FINAL GRADE
ELEVATION
//2- Feer
YII. TAilK
tltFoRltATtoN
CAPACITY
ln oallons Total
Gallons
#ol
Tanke Manufac'turer'g Nsme Prefab.
Concrete
Slte
Con-
structed
Steel Flber-
glass Plastlc Exper
App.New
Tanks
Seollc Tank or Holdlno Tank l2.oo /2O,4 T qtc.?T)
-T tl n n
Llft Pumo Tank/Slohon Ghambor PQ to/)I A.uqtQ ry tr n t1
YIII. RESPO}ISIBILTTY STATEIIENT
l, the underslgned, asaumo responslblllty lor lnstallatlon ol the oneite sowago systom shown on the attached plans.
RuWr zlltlrchT ffilupnsw no.:
37o1
Burlncor
(7/9 \iw
Plumber'g Addross (Strest, Clty, State, Zlp Codej: t ^/GSS Ot alat ( /€4 t7V Dto.t hst f- f t/o/_L<
lx./DEPARTIIENT USE ONLY
fr oro,o,u
tltl Dlcapproved
Ourner Glven lnltlal
Adverge Delermlnallon o Fcc)s;-
7
X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROYAL:I
SBO{398 (formcrly Plb{7) (R. 11/SS) OISTRIBUTION: Orlglna! to County, One Copy To: Satcty & Bulldlngo Dlvlglon, Ofncr, Plumbcr
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tltrnT
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