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m� SANITARY PERMIT APPLICATION to CA <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STATE SANITARY PE MIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ��Y � 7 <br /> 834 x 11 inches in size. ❑ Check if revision o previious 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 OW PR �RTYL C TION <br /> U/'/a,S t� TQ® , N, R I (o <br /> PROP RTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> p, 1--- <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> C4v6vQ rq,1i - 5W340 .� <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned o VILLAGE � � � k'e% <br /> ❑ Public 1 or 2 Fam. Dwelling—#�of bedrooms RCELTAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) 10 <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. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> stem 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 /> 11Sepage Bed 21 ❑ Mound 30 L1 SpecifyType 41 El Holding Tank <br /> 12 Ks:epage 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 12.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) I ELEVATION <br /> 303ep--- i7 Feet �+ Feet <br /> VII. TANK CAPACITY f <br /> Site <br /> in gallons Total ##of Prefab. Fiber- Exper. <br /> INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank t� <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber' Lure: o Stamps MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 1lo` / S- J);9R X 4P <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e ue Issuing Ag t Si at ( tamps) <br /> Approved ElOwner Given Initial Surcharge Fee) / <br /> Adverse Determination [ / <br /> X. CONDITIONS OF APPROVAL/REASONS F SAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety R Buildings Division,Owner,Plumber <br />