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mm" <br /> U77ffql!L H 4 SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code couNTv <br /> bi r <br /> STATE SANITARY P MIT# Ig/ll h� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ Cl(:2�qg) VII VV <br /> B'%x11inches Insize. Check if revislonJ6 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 .. rr PROPERTY LOCATION <br /> D U� (N `--'!fes %4, S 2-3 T Q, N, R E (o W <br /> TOWN <br /> PROP R OWNER'S MAILING ADD SS LOT# BLOCK# <br /> pi� <br /> 01 ;+k k• 1 -� • 33 <br /> CITY, TATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER , /, t /' <br /> NI V V <br /> 11. TYPE OF BUILDING: (Check one) CITY : NEAREST ROAD <br /> $tate OWDed VILLAGE <br /> ❑ Public LJ 1 or 2 Fam. Dwelling—#of bedrooms <br /> ANUFRAXINIUMIJImi-I(b)) <br /> III. 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 only one in line A. Check line B if applicable) <br /> A) 1. New 2. ElReplacement 3. ElReplacement of 4. ElReconnection 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 /> Nona��-P-,,,,,,,,{{{{{ressurized Distribution Pressurized Distribution Experimental Other <br /> 11 1,�) Seepage Bed 21 El Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 1 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 13.ABSORP.AREA 4. LOADING RATE5. PERCRATE 6. SYSTEM ELEV. T FINAL GRADE <br /> 3 REQUIRED(sq.ft.) PR P SED(sq.ft.) (Gal;/day/sq.ft.) (Min./inch) E VATION <br /> Feet Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name c ncret Con- Steel glass Plastic App <br /> T nks Tanks structed <br /> Septic Tank or Holdino Tank <br /> Lift Pump Tank/Siphon Chamber EL71 LEI <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' Signature: No mps) MP/MPRSW No.: Business Phone Number: <br /> 4� <br /> � �eb A/S -51 Zf, l 6 . <br /> Plumber's Address(Street,City,State,Zip Co ): <br /> 'Z bo w �� S <br /> IX. OUNTY/DEPARTMENT U ONLY <br /> Disapproved Sanitary Permit Fee(Inclu, Groundwater Dale wu Issuing gent Signature(No Stamps) <br /> Surcharge Fee) ry <br /> Approved E] owner <br /> Given Initial LX.J <br /> A v D termin tin I�. <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&Buildings Division,Owner,Plumber <br />