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SANITARY PERMIT APPLICATION COUNTY <br /> C�IILHR In accord with ILHR 83.05,Wis.Adm.Code �lrn <br /> p��•��� STATES ITARY RMIT# 6)� <br /> -Attadh complete plans(to the county copy only)for the system,on paper not less than <br /> 8%x 11 inches in size. ❑ Check if revisiffffn 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 /> PROPERTY OWNER PROPERTY LOCATION <br /> !`-4. tf S UE Y4 ,(1 '/4,S T /, N, R / 45 B (OCW-)- <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> O �_ S Rare. ,4U s --All' <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 8 m 5N, 9,o1 1� 3 0571 V. SIS <br /> II. TYPE BUILDING: (Check one) CITY - NEROADROAD /� <br /> ❑State Owned VILLAGE S W/ t yr <br /> dF <br /> El Public ©1 or 2 Fam. Dwelling,#of bedrooms a PAR L X NUMB ) <br /> III. BUILDING USE: (If building type is public,check all that apply) 3a (;)-)I? <br /> 1 ❑ ApVCondo <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. �j 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) <br /> 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 ❑ 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 14. LOADINGRATE 5. PERC.RATE 16. SYSTEMELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 3 n d q /t9 y3 Feet ®,16 Feet <br /> VII. TANK CAPACITY Site <br /> in allona Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdin Tank SO f TMC <br /> Lift Pum Tank/SI hon Chamber ?SO 7 C <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): I PT r's SignaWre: oStamps) MP/MPRSW No.: Business Phone Number: <br /> IJ ,ehl tar O �' 7/�' �6b•fd/S� <br /> Plumber's Address(Street,City,State,Zip Code): <br /> W,Q rr- <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Intruder Groundwater =eu�� Is iAgentSign re(NoStamps) <br /> /05^CC aurcharpe Fee) <br /> Approved Owner <br /> A r D termin i n <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 />