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SANITARY PERMIT APPLICATION COUNTY <br /> (� DILHR In accord with ILHR 83.05,Wis.Adm.Code G, ,f n t+ <br /> 1 <br /> ~�• mm STATE SANITY PERMIT.# �Lt(C$CO <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than C (i-kk46\\J <br /> 8'%x 11 inches in size. ❑ Check if revision 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. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> 4 4 n E,Q /--e ✓ W '/4 S,E'/4, S 3 T 1%, N, R /3-E (or) W <br /> PROPERTY OWNER'S MAILIIJGADDRESS LOT# BLOCK# <br /> f-S R 0 V At''C <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAM OR CSM NUMBER <br /> 9i C hn r" .l 38 Q l/ ,�i a AJ <br /> II. TYPE OF BUILDING: (Check one) CITY �` NEA ST ROAD n <br /> ❑ State Owned VILLAGE L _ / eQ /F <br /> ❑ Public ®1 or 2 Fam.Dwelling-#of bedrooms— AR ELT UMBER(S) <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 ❑ 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. X 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 /> 11Seepage Bed 21 ElMound 30 ElSpecify Type 41 ❑ Holding Tank <br /> 12 N 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.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) ( i /inch) EL VA710N <br /> 3 l G y / © f 7"' Feet y ` Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New iatin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 7�� t L_SL <br /> Lift Pum 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): P�h�mlbers�qSigna�ture,(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> o Crit k /�o . lsitis vl 03 eS9 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> f_l <br /> W� W.1:e- S, V dQ <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date IssuedIs m Agent SI re(No Stamps) <br /> Surcharge Fee) / <br /> Approved ❑ owner Given initial tSb "'7 Zc_u <br /> Adverse r D termin ,S1bS� <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />