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SANITARY PERMIT APPLICATION COUNTY <br /> �P&HR In accord with ILHR 83.05,Wis.Adm.Code Cir ' rnetlt7 <br /> STATESANITAR\�PERMIT#�� <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ❑( ib&q5 <br /> 8'%x 11 inches in size. neck if rev99'' n to 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 /> PROPER OWNER PROPERTY LOCATION <br /> '/4 ''/4, S 35 T lIIrr <br /> (, N, R I� E(or) W <br /> PROPERTY OWNER'S MAILING ADDRESS_ LOT# BLOCK# <br /> S NO Se 5 <br /> ITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> FLP es <br /> It. TYPE OF BUILDING: (Check one) CIN N AREST ROAD <br /> ❑ State Owned VILLAGE SW (�5 AGE VIZ- <br /> SW <br /> X1 or 2 Fam. Dwelling–#of bedrooms LTAXNU ( ) VV <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.❑ 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 Ys1 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 DAY 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 5. PER'.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> RE IRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft (Min./inch) a ELEVATION <br /> 2C fjZo .(PZ 3 IS• 3 Feet "TIFeet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or HoldingTank kwo <br /> Litt Pump Tank/Siphon Chamber <br /> Vlll. 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 S ) MP/MPRSW No.: Business Phone Number: <br /> (ONR(L10 roPWVJ5 mps.- j lS gI66- 1ST <br /> lumber's Address(Street,City,Stjte,Zip Code): I . ,` RR <br /> W 1y 3 <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e ssu Issuing Agen ign lure( mps) <br /> Approved ❑ Owner Given Initial I �� Surcharge Fee) ' <br /> Adverse De ,min tion <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 />