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SANITARY PERMIT APPLICATION COUNTY <br /> ,DILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITARYRMIT#Xo535 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than C 1 61(94 7 <br /> 8'%x 11 inches In size. ElCheck if revisio 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. b <br /> PROPERTY OWNER PROPERTY LOCATION <br /> UK S 2—q <br /> T O, N, R & E (or W <br /> PROP TYOWNER'S MAILING ADDRESS LOT# BLVCR" <br /> �ktk_ll � • Cif / <br /> CITY,STATE ZIPCODE PHONE NUMBER stmq i BI9M MkMEeRCSM NUMBER <br /> Zr (L Ma 3 a S3-fd4 Csm _ 2-0 <br /> Li It. TYPE OF BUILDING: (Check one) L1 State Owned jiifiVILTMLAGE L ND NEAREST ROAD INF <br /> ❑ Public Pq 1 or 2 Fam. Dwelling—#of bedrooms 3— PARCEL TAX NUMBER(S) <br /> DI-goo <br /> III. BUILDING USE: (If building type is public,check all that apply) 0�-- O — <br /> 1 ❑ Apt/Condo <br /> 2 ElAssembly 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 /> 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 41Holding Tank <br /> 12 El 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 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 4� REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank orHoldin Tank 0eF1_ 4 2 <br /> Lift Pum TanWSi hon Chamber <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): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> lC Fl2D DPK./NS 1 14 ti Z(o 118 Qib6 yES 1 <br /> Plumber's Address(Street,City,Stale,Zip Code): <br /> 27 !c0w 35 W UWS GZ W t . S`IS 3 <br /> IX. OUNTY/DEPARTM NT USE ONLY <br /> Disapproved I Sanitary Permit Fee(Includes Groundwater a e Issued Issuing Age. t ignat 'etrio s) <br /> Approved ❑ Owner Given Initial 'y�y�- <br /> a.Owner <br /> Fee) <br /> Adverse Determinati n `T' /�0 w <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 />