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SANITARY PERMIT APPLICATION &-a In accord with ILHR 83.05,Wis.Adm.Code couNrY <br /> STATE SANITARY PERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than - <br /> 9 •77? <br /> 6%x 11 inches in size. Che k 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 /> 1. �� (,)% (J'/a, S 3 -)- T,3 7 , N, R L'/ E (or)Q <br /> PROPERTY OWNER'S MAILING A DRESS LOT# BLOCK# A, <br /> A // <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> r 11A <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> {{�� State Owned QQ O VILLAGE:EX TOWN OF' s t e e <br /> ❑ Public X 1 or 2 Fam. Dwelling—#of bedrooms�L PARCEL TAX NUMBER(S) <br /> 111. BUILDING USE: (If building type is public,check all that apply) L/—,� 1 —Ol-700 <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 [1Outdoor Recreational Facility <br /> 3 ❑ Campground 7 E] 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 /> 11Seepage Bed 21 ❑ Mound 30 ElSpecify 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 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> Ll <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) !To ELEVATION <br /> 7 <br /> , j-D 010 7 0�a . (� 3 6't Qc// Feet moi, 0 Feet <br /> VII. TANK CAPACITY Site <br /> in alIons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New ExistingGallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank Doo p /;0 o / n G <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:(No S ps) MP/MPRSW No.: Business Phone Number: <br /> ,��t- ��1s��. oG d <br /> Plumber's Address(Street,City,State,Zip Cod <br /> Ll� RL ons /:3 <br /> IX4 UN DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date ssue Is Ing A ent Signature amps) <br /> Approved ❑ Owner Given Initial Surcharge Fee) 6., <br /> AdverseDetermination " ���' ` �� /7 7 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL. <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />