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1001011 SANITARY PERMIT APPLICATION <br /> IR In accord with ILHR 83.05,Wis.Adm.Code COUNTY"{1 <br /> Cu r <br /> STATE SANITARY ERMIT <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> ❑ /�7� j <br /> 8%x 11 inches in size. ceckirrevisl topreviouaepplication <br /> -See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> �QQ /a '/s,S <br /> T N, R( G E(06,W) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 21 180 H w 19? <br /> — <br /> CITY,STATE I <br /> ZIP COD PHONE NUMBER <br /> MOM 96 , W 1 S fl�KES <br /> CITY : NEAREST ROAD <br /> 11. TYPE OF BUILDING: (Check one) L-1stateOwned "IQANQONV VILLAGE (,1 Ia 1 )�) �S D <br /> El Public 191 or 2 Fam.Dwelling—#of bedrooms Z V <br /> 111. BUILDING USE: (If building type is public,check all that apply) Llc� <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. TYPPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1.9 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 Cil 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 12..ABSORP.AREA 3.ABSORP.AREA 14. LOADING RLO ATE 5. PERC.RATE 6. SYSTEM ELEV. 7.FINAL GRADE <br /> REO IRED(sq.tt.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> _300qy. ZFeet Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> nks Tanks strutted <br /> Septic Tank or Holding Tank <br /> Litt 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:( S psI MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code <br /> 2.'1'16o HW 35 68SrE2 I LJ I . SLIM <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(includdSurchegge Groun water a e ssu Issuing a wig re( ps) <br /> Approved Owner Given Initial I <br /> _ L-�_) �_��.-� •� <br /> Adverse Determination' �} <br /> X. CONDITIONS OF APPROVALIREASONS 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 />