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SANITARY PERMIT APPLICATION COUNTY <br /> 7DLLHR In accord with ILHR 83.05,Wis.Adm. Code <br /> STATEPANITARYPERMIT#,/� j' b <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �j r rc����r� <br /> 8%x 11 inches in size. ❑ c �kU on to 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. U <br /> glo <br /> PROPERTY OWNER PROPERTY LTION <br /> '/a Ya, S 29 T 39 , N, R 16 E (Or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 25400 Old 35 <br /> CITY STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> webz.ten, wI 54893 715 866-8319 oct. SW 114 NW 114 <br /> I1. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ❑ State Owned VILLAGE: Meenon O�d 35 <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms 2 N <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 ❑ RestaurantIBar/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 REQUIRED(sq.ft.) PROPOSED(sq.ft.) 4 (Gals/day/sq.ft) 15. (MInCi R TE 6. SYSTEM ELEV. 7' ELEVATION E <br /> 450 750 800 .56 5 100.4 Feet 102.7 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name ConcreteCon- Steel glass Plastic App <br /> structed <br /> Tanks I Tanks <br /> Septic Tank or Holding Tank 00 1 ,000 1 Wieeen <br /> Lift Pump Tank/Siphon Chamber --- -ng 1 SkaU1 <br /> Vill. RESPONSIBILITY STATEMENT 8(0 <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): ignature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> PL <br /> Ru 40'-M Plumber's S 3361 715 349-7286 <br /> PPlumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.U. Box 514 S nen W1 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY Issuin ent Si nature(No Stamps) <br /> DlsapProved Sanitary Permit Fee(Includes eroundweter a e esus 9 9 <br /> ,,�11I++-� Surcher ge Fee) <br /> Approved ❑ Owner Given Initial c11IOG <br /> A verse termin tion yf l J vlJ <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 />