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SANITARY PERMIT APPLICATION <br /> 7_0ILHR In accord with ILHR 83.05,Wis.Adm. Code courin <br /> �• � STATE§§§ANITARY PERMIT#4UJNMW <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than (6153) <br /> 8%x 11 inches in size. ❑ Check if revision to previous e�icat n <br /> -See reverse side for Instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PRO7 OWNER PROPERTY LOCATION - <br /> '/,S(t�/a,S 7 TN, R /(P E(or <br /> PROP R ER' MAILING ADDRESS LOT# BLOCK# <br /> i ref e. S 7 <br /> C71 .S TE /YJ ZIP CODE PHONE NUMBER BDIVIS N NAME OR CSM NUMBER <br /> 11. TYP OF BUILDING: (Check one) ElState Owned a VILLAGETY NEAREST ROAD <br /> 14 QXg RF ,E/O/CG <br /> ❑ Public 1 or 2 Fam.Dwellings of bedroomsPARCEL I AX NUMBER(b) <br /> III. BUILDING USE: (If building type is public,check all that apply) -RQ <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 IS if applicable) <br /> A) 1. New 2. ElReplacement 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-���P(({ressurized Distribution Pressurized Distribution Experimental Other <br /> 11 �f Seepage Bed 21 [1Mound 30 El SpecifyType 41 El 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 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIR D(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) C/yam ELEVATION <br /> �-�✓ Q / �J /L� Y Feet Y. � Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank <br /> Litt Pum TanWSi hon Chamber CTJ <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' o Stamps) MP/MPRSW No.: Business Phone Number: <br /> 7/5 - <br /> Plumber'sOdresa(Street,City,State,Zi Code): <br /> U ���/ Lc /1 5 ?9 <br /> X. OUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issu' gent Sign tura(No Stamps) <br /> Approved U- Surcharge Fee) <br /> ❑ Owner Given Initial 4f,la Oa g, <br /> Adverse Determination �1V II=J 'f <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 />