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SANITARY PERMIT APPLICATION ' Iv- <br /> CWtH-9 <br /> In accord with ILHR 83.05,Wis. Adm. Code couNTYBurneN <br /> STATE SANITARY�RM A4� <br /> j <br /> IT L <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than °�J �� �r <br /> 8%X11inches Insize. ❑ Checkifrevisio o 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 /> PRO TY OWNER ;PROPERTYLOCATION111� ''/4 '/4, S T N, R E (OrlyP OPER WNER'S AIL G RE BLOCK# <br /> CIN ST IPCODE PHONE NUMBER 9R99FFN INBERrED <br /> II. TYPEOF BUILDING: (Check one) TY NEAREST OAD <br /> F!!-Irl <br /> y ❑ $tate DWned LLAGE:aigOWU RF �'r <br /> ❑ Public LJ 1 or 2 Fam. Dwelling-#Of bedrooms 3 PARCEL TAX NUMBER(U) <br /> III. BUILDING USE: (If building type is public,check all that apply) �(., -�C)�jO- c)5k- <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. TYPPEE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> IrJ <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 PE7 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. FERC. RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) p ELEVATION <br /> ,s — / Feet r Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #:of <br /> Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank <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 /> ber's Name(Print): ��, Plum 'it Signature, No %§m ) IdP/MPRSW No.: Business Phone Number: <br /> S <br /> umber s dr (Str et,Cify,State, p C e: <br /> 1 <br /> I)( ObUNty/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sant ry Permit Fee (Inclueen Groundwater Date sue Iss n Agent Sig re(No Stamps) <br /> Approved ❑ Owner Given Initial I_ surcharge Fee) /n <br /> AdverseDetermination I C_J .� �" <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb$7)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />