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�I�.HR 17- SANITARY PERMIT APPLICATION COUNTY U <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> No <br /> STATE SANITARY����FFFFRMIT#� <br /> RN E- <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than SANITARY <br /> 814 x 11 inches in size. ❑ check if revisio o previous application <br /> -See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROP TY OWNER rPROPERITY LOCATION <br /> / � /a, S T /_, N, R E(orPROPER OWNER'S MAILING ADDRESS BLOCK# <br /> CI STATE ZIPS - PHO UMBER AiVISION vAsicinE OR CSMNUMBER <br /> ul/LlSi2C` aRII. TYPE OF UILDING: (Check one) ❑State Owned Li GE N NEAREST ROAD <br /> f <br /> ❑ Public Z or 2 Fam. Dwelling-#of bedrooms L AX NUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) 5 C_:�S <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. I�� 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 /> 11Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 8 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 512.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(s .ft.) PROPOSED sq.ft.) (Gals/day/sq.ft.) (Min./inch) ATION <br /> �� 1 / 0.::;-Feet / / Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New satin Gallons Tanks oncret glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank / <br /> Lift Pump Tank/Siphon 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/MPGR-SWW No.: Business Phone Number: <br /> Plumber's dress(S eet,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued nt Sign toe(No Stamps) <br /> Approved ❑ Owner Given Initial I1� „, Surcharge Fee) /0 <br /> Q <br /> Averse Det rmin ti n VVV....YYV V (v <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 />