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SANITARY PERMIT APPLICATION <br /> 1.7— SANITARY In accord with ILHR 83.05,Wis.Adm.Code couNTV <br /> — - r <br /> �• � STATESANITARY PITMIT# 15137 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than (I 5yT ;q ) <br /> 8'b X 11 Inches In size. ❑ Check If revisioD&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 /> PRO ERTY OWNER PROPERTY LOCATION <br /> PI �(y( W'/4 '/4, S T �, N, R � � E(D W <br /> P OPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> ov . 5 . <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> NEA EST ROAD <br /> II. TYPE OF BUILDING: (Check one) F-1qt-t.Owned CITT AGE <br /> 1_ <br /> El Public 1 or 2 Fam.Dwell ing-#of bedrooms— Ax Num v <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 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 12.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSEDD(sq.ft.) (Gals/day/sq.ft.) Min./inch) ELEVATION <br /> 3 oO V h 4 • �'"' r Feet ,.7 .Q Feet <br /> VII. TANK CAPACITY Site <br /> Ing al Ions Total #of Prefab. Fiber- Exper. <br /> INFORMATION New ExistingGallons Tanks Manufacturer's Name cncret Con- Steel glass Plastic App <br /> Tank Tanks structed <br /> Se tic Tank or Holdin Tank •� C- <br /> LiftPum 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 Signature:IN S mpsI MP/MPRSW No.: Business Phone Number: <br /> R go n k (S <br /> lumbers Address(Street,City,State,Zip Code): <br /> 2_ w 3S E$5T <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> 10 Disapproved Sanitary Permit Fee(Includes Groundwater a e ssue Issuing t Signature( c Stamps) <br /> pproved E] Owner Given Initial (��Surcharge Feel <br /> Advers rm'nation ,y�.}� ns. `-'�-' <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 />