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SANITARY PERMIT APPLICATION Co NTY (� <br /> E <br /> annr"� In accord with ILHR 83.05,Wis.Adm.Code " ' <br /> STA EI�SANI1�5��RYPERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less thanci,kR o J ^�3-WCS <br /> 8t/2 x 11 Inches In size. Check if revision to previous application <br /> application. ST TE PLAN I.D.NUMBER <br /> -See reverse side for instructions for completing this app ' <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION / <br /> �N I S 1/4 1/4,S T N R !' E (or <br /> PROPERTY OWNER'S MAILING DRESS <br /> LOT# BLO K# <br /> ZIS a N <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER XlvI <br /> b •' NEA ESKM FFiRCUNE <br /> T ROAD <br /> 11. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE: <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms A ELTAX NUMBER(b) <br /> 111. BUILDING USE: (If building type is public,check all that apply) �o I -o1—� <br /> ct <br /> 1 ❑ Apt/Condo 10 ❑ Outdoor Recreational Facility <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 11 ❑ Restaurant/Bar/Dining <br /> tdoRecre <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Ot er: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line a if applicable) <br /> Repair of an <br /> A) 1.�New 2' ❑ Replacement <br /> ment 3. Rank Only <br /> of 4' ❑ Ex sting System 5.❑ Existing System <br /> System SystemSystem <br /> B) ❑ A Sanitary Permit was previously issued. Permit# <br /> Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental <br /> Other <br /> 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ HoldingTank <br /> ❑ pit Privy <br /> 12 ❑`Seepage Trench 22 ❑ In-Ground 43 ❑ Vault Privy <br /> 13 ❑ Seepage Pit Pressure <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: FINAL <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. P�RC.I RATE 6. SYSTEM ELEV. 7' ELEVATION <br /> GRADE <br /> REQUIRED(sq.ft.) PROPOSE��D_(sq.ft.) (Galslday/sq.tt.) ( 6. 9 Feet <br /> 3©o z 9 7 Feet <br /> CAPACITY Prefab. SitelExper. <br /> VII. TANK in allons Total #of Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> INFORMATION New istin Gallons Tanks structc d <br /> Tanks Tanks <br /> Se tic Tankor Holdin Tank <br /> LittPum Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attacritlu plans. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) <br /> MP/MPRSW No.: Business Phone Number: <br /> 3 Z(o S G lS <br /> Ic RD <br /> umber's Address(Street,City,Stale,Zip Code: !Q M ( D q <br /> J Ol <br /> IX. COLINTYIDEPARTMENT USE NLY Issuin g t ignpnNomps) <br /> ❑ Disapproved Sanitary erwater ae ssue <br /> 1 . :charYe Fee) <br /> Approved ❑ Owner Given Initial IN\ � CIU <br /> Adverse Det rmination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division.Owner,Plumber <br />