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SANITARY PERMIT APPLICATION COUNTY�' I <br /> 17—_DILHR In accord with ILHR 83.05,Wis.Adm.Code L J�I•n� <br /> �• _� STATESANITARY PRCMIT#l1�6p <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �Jo��� <br /> 8%x 11 inches in size. ❑ Check If revisio,,,;;;,,400 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 /> PROARTY OWNERPROPERTY LOCATION <br /> p ala"/4, S"33 T q6, N, R I jo E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# <br /> FL, Z C, - L- '7 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> f-01 R MrJ 0g2r602 m v. P o <br /> It. TYPE OF BUILDING: (Check one) ❑State Owned VILLLLAGE Nn N REST ROAD <br /> ❑ Public1 or 2 Fam. Dwelling-#of bedrooms— A <br /> 111. BUILDING USE: (If building type is public,check all that apply) <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 my one in line A. Check line B if applicable) <br /> A) 1. El New 2. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System ystem 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 PERDAY 2.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.) (Mi inch) ELEVATI N <br /> 300 Q CoZ -D Feet Feet <br /> VII. TANK CAPACITY Site <br /> ingallons I Total #ofPrefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> anks Tanks strutted <br /> Septic Tank or Holdin Tank <br /> Lift Pum 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's Signature:(No mPsi MP/MPRSW No.: Business Phone Number: <br /> c opwiIJS 7_G (5 $66 S <br /> Pitimber's Address(Street,City,State,Zip Code): <br /> Er?1(0U w 35EBST61 1. S4 5 <br /> IX.jCOUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date ssue Issuing Age gnatur No t psi <br /> Surcharge Feel <br /> Approved ❑ Owner Given Initial I �C' <br /> A verse Determin <br /> on J <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />