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_- mm" SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> M� STATES NITAR ERMIT# ��z5�� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �l�l{ <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 /> 1. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> SL ) '/4 � '/a, S � T 11 N, R 19E (or W <br /> P I P 2TTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> CITY.STATE 21P PHONE NUMBER SUBDIVISION ME OR CSM NUMBER <br /> JyC� '(2311 '� Ca>se�:c LNo )._a <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST OAD <br /> �y ❑ State Owned O VILLAGE t 1 � ALL pu LflKc CCf1 Gc Q2 <br /> [] Public Ldl1 or 2 Fam. Dwellin"of bedrooms 3 EL AUUVM R( ) <br /> 111. 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 ❑ RestauranUBar/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. TYPEI OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1.Z 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 El 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 3.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> s REQUIRED(sq.tt.) PR/OPOSEtD�(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVAATION <br /> [� (0 �J c� O 4 �p I � ,j. Feet D Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Expp. <br /> INFORMATION Manufacturer's Name Con- Steel Plastic <br /> New istin Gallons Tanks Concrete strutted 91ass App. <br /> Tanks Tanks <br /> Septi Tank orHoldin Tank Tanks <br /> C i <br /> Lift Pum Tank/Si hon 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 Siginatur No mps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Addrea�StreetC <br /> , iWuete,Zip Code): <br /> 2 TEg w <br /> IX. OUNTYIDEPARTMEN USE ONLY <br /> Disapproved Sanitary Permit Fee(I8 rchae Groundwater a e esus Iss mg gent Sign o Stamps) <br /> �0❑r �3u chergeFee) <br /> Approved ❑ Owner Given InitialAdverse ,�- <br /> r in ti <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> r <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumbs <br />