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SANITARY PERMIT APPLICATION COUNTY <br /> 7DILHR In accord with ILHR 83.05,Wis.Adm.Codeh2tJCI <br /> STATE SANITARY ERMIT#I(JP <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than /'15535 <br /> 8'%x 11 inches in size. ElcheckIf revislo 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 /> PROP TY OINNER PROPERTY LOCATION <br /> '/4 '/4,S tJF N, R E(Dr <br /> PRO TYe7NER'S MAILING ADDRESS /!` L BLOCK# <br /> CITY ST TE ZIP C PHONE NUMBER SUBDIVI ION AME OR CSM NUMBER <br /> �Mr tli U� t i Cin V.3, X93 <br /> II. TYPE OF BUILDING: (Check one) CIN NEAR ROAD <br /> ❑ State Owned NI <br /> � LLAGE <br /> ❑ TAX <br /> Public 1 or 2 Fam. Dwelling–#of bedrooms— R TAXN MBER( <br /> Ill. BUILDING USE: (If building type is public,check all that apply) J4— aao�' lJ� <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 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PR OS (sq.ft.) (Gals/day/ q.ft.) (Min./pinch) ELEVATION <br /> Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allot Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's f�5me oncrete Con- Steel glass Plastic App <br /> Tanks Tanks Ofe ?- strutted <br /> Se tic Tank or Holding Tank <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:(N Stamps) MP/MPRSWNo.: Business Phone Number: <br /> Plum ber'a Address(Street,City,State,Zip ef.� <br /> LINTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanita Permit Fee itnciudes Groundwater a e ssue ?7"!, <br /> ant Signa r (No Stamps) <br /> /� ��yysu'�roherge Fee) /N�i� <br /> pproved ❑ Owner Given Initial I US•LTJ II-I� < V <br /> Adv Determination <br /> X. CONDITIONS OF APPROVALIREASONS 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 />