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Ar ;�.:..�� SANITARY PERMIT APPLICATION <br /> COUNTY 00 C6-itiPs <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITA/R7ER <br /> #-Attach complete plans(to the county copy only)for the system,on paper not less than 78%x 11 inches in size. Check if revvious application <br /> —See reverse side for Instructions for completing this application. STATE Mtn <br /> NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROP?OWNER . PROPERTY LO TION <br /> ✓ ) IUf,(i4'/a,S 3a- T `/ l, N, R 1-9-M to W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 3o 2i l0 w�L � <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> CIN NEAREST ROAD <br /> II. TYPE OF BU LDING: (Check one) <br /> ❑State Owned ILLAGE: <br /> ❑ Public Xtor 2 Fam. Dwelling-#hof bedrooms PAR ELTAxNUMBER(S) <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. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.El Repair of an <br /> Existing System Existing System <br /> System System Tank Only <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 30,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 D 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7' ELEVATION FiNALGRADE <br /> AY <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) <br /> Feet <br /> VII. TANK CAPACITY Site Fiber- Exper. <br /> in allons Total #of Prefab. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 751Y1 <br /> Lift Pum Tank/Si 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 re:(No Stamp MP/MPRSW No.: Business Phone Number: <br /> - Z<Stamp <br /> (93 0'7 :� 7l� 24e1-3So <br /> Plumber's Address(Street,City,State,Zip Code): I /tc y g 3 <br /> 6 / �i4 ��v <br /> IX. COUN DEPARTMENT USE ONLY ate s ue Issuing Agent Signature tam <br /> Disapproved Sanitary Permit Fee(includes Groundwater <br /> may( ❑ — _� Surcharge Fee) <br /> Approved ❑ Owner Given Initial /5: , �Y <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: IV <br /> SBD-8398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />