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wommill SANITARY PERMIT APPLICATION COUNTY <br /> i In accord with ILHR 83.05,Wis.Adm.Code BuRjJ E'1- <br /> .�., STATE NITARY P MIT#) 5 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8%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 /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> E '/a Ya, S TN, R S E(o <br /> PROPERTY OWNER'S MAILING ADDRESS LOT BLOCK# yl <br /> '119 ST Un G <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> �J -55119 12 -3651ILKAK K tZd <br /> I. TYPE OF BUILDING: (Check one) CITY _ AA Vc N D I NEAREST ROAD <br /> I <br /> l� ❑State Owned vII LaGE .FJ RE <br /> N QF <br /> ❑ Public LX11 or 2 Fam.Dwelling-#of bedrooms— PARCEL TAX Nu <br /> 111. 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. 14 New 2. ❑ Replacement 3. El 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 M 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 DAI 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) p ELEVATION <br /> 3M G D` . (0 -1 .0 Feet I -n Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New i din Gallons Tanks Manufacturer's Name Concretestrutted Con- Steel Plastic <br /> glass App <br /> Tanks Tanks <br /> Septic Tank or Holdin TankM L <br /> Litt 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/MPRSW No.: F115 <br /> iness Phone Number: <br /> r c(-(A o o I KS 3�f Z6 $bb- y I S 7 <br /> Plumber's Address(Street,City,Stale,Zip Code): \ ��� <br /> 35' WE � °13 <br /> IX. OUNTY/DEPAR MENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Gro undweterae sou issuing Age 1Signature(N Stamps) <br /> �{- Surcharge Fee) <br /> Approved ❑ Owner Given Initial `1-b <br /> TN <br /> IS- —7a X <br /> A verse rmin i n <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 />