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FZW�H�ssss`assnSANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> r <br /> STATE SANITARY PERMITt/i3-7 Z3 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 6�t�t0(Q \/ <br /> 8'%x 11 inches in size. ❑ Check if revision to 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 PftOPERTY LOCATION <br /> '/a ''/a, S TN, R IS- E(o W <br /> PR PE TY gNf}i'S MAILIN ADDRE ^� LOT# A BLOCK# <br /> CITY,STATE �S ZIP CODED PHONE NUMBER_ SUBDIVISION` NAME OR CSM NUMBER <br /> II. TYPE OF BUILDING: (Check one e O �INEAREST CITY gC O LN� ROAD <br /> State Owned ❑ VILLAGE <br /> ❑ Public 1 ort Fam. Dwelling-#of bedroom-%s A LTAX NUMB <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo 1 <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.)4 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 /> 11 Seepage Bed 21 ❑ Mound 30 ❑ Specity 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 DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PER'.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> O REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Ill <br /> ELEVATION <br /> -1 ( b e ( I /• Feet •5-Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New istin Gallons Tanks oncrete structed glass App. <br /> Tanks Tanks <br /> Septic Tank or Holdinct Tank L <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): PI Signgture:(N Sta ) MP/MPRSW No.: Business Phone umber: <br /> w C NDPKINS 3oS� �1S 21"_ 9+51 <br /> Plumber's Ad_7(X,7_eet,Cipr,*te,Zip:3 g- <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fe ,(Includes Groundwater a esau Iss ' Agent Sign to (No Stamps) <br /> Approved E] Owner Given Initial �� surcharge Fee) <br /> Adverse Determin ti SCS-- S �'� <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 8 Buildings Division,Owner,Plumber <br />