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MMI SANITARY PERMIT APPLICATION <br /> DILF'IFR In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> �• _ STATE SANITARYYY�ERMIT#,10) <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ C�7f <br /> 8%x 11 inches in size. cbeckrrevi ntopreviousapplication <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 /> Y. Ya,S T , N, R E(4)W <br /> PROPERTY OWNER'S MAILING ADDRESS' LOT III BLOCK# <br /> CITY,STATE I ZIP COD PH NE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> CI <br /> 11. TYPE OF BUILDING: (Check one) TY NEAREST ROAD' <br /> ❑State Owned ILLAGE <br /> ❑ Public X1 or 2 Fam. Dwelling-#of bedrooms L <br /> III. BUILDING USE: (If building type is public,check all that apply) -AO- vl 3-6 C)I --_250� <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.)Gew 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 13.ABSORP.AREA 14. LOADINGRATE 15. PERC,RATE 16. SYSTEMELEV. 7. FINAL GRADE <br /> /� RE UIRED(sq.tt.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> -i.XJ tp L . L. Feet Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in al Ions Total #of Prefab. Fiber- Exper. <br /> INFORMATION New inti Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdin Tank <br /> Lift Pum Tank/SI hon 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(Prin P r'a Signature: No mpg) MP/MPRSw No.: Busess Pho Number: <br /> (S S <br /> lumber'sdress(Street,ci tate,zip C ): <br /> 2-77(c, o w' 3- > ) <br /> IX. COUNTY/DEPARTMENT UISE ONLY <br /> ❑ Disapproved Sanitary Permit Fse(Includm GroundwaterDae ssue Issuing g toi n re N mps) <br /> Approved ❑ Owner Given Initial --I$ I� M Surcharge Feel 7q <br /> AdvDetermination J�J� <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 />