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Cm cam, <br /> SANITARY PERMIT APPLICATION <br /> 5ILHR In accord with ILHR 83.05,Wis.Adm.Code coulv? � <br /> �• �_ S A 6A'I RY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than W9 3 41^1 I k3 z>O <br /> _n <br /> 8'/z x 11 inches in size. heck h revision to previous application �T <br /> -See reverse side for instructions for completing this application. S7 E PLAN 1 g NUM_ s <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERIYIY.WNER PROPERTY LOCATION tL <br /> n� ,eA e 47_% �''/s,S d;7 7 T 15, N, '1' aw W <br /> PROP/E�RTY OWNER' AILING ADDD'Rg§3 LOT# BLOC # <br /> CITY,STATE ��j 21P CODE�7 PHONE NU BER SUBDIVISION NAME OR CSM NUMBER <br /> 54(5 <br /> It. TYPE OF BUILDING: (Check one) ❑State OwnedCILTY NEAR ST ROADae <br /> El Public X 1 or 2 Fam. Dwelling-#of bedrooms AR EL 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 ❑ Out oor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 El Res urant/Bar/Dining <br /> 4 <br /> El 8 ❑ Mobile Home Park 12 ❑ Se ice Station/Car Wash <br /> 5 ElHotel/Motel 9 ElOffice/Factory 13 D-1Oth r: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. ❑ New 2. OReplacement 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 M Mound 30 ❑ Specify Type 41 El HoldingTank <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 13.ABSORP.AREA 14. LOADINGRATE 5. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> /fit REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) (� [ ELEVATION <br /> 4p'00 QQ -) ,, Feet 1��eet <br /> CAPACITY <br /> VII. TANK in allons Total Site p <br /> #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks struded <br /> Septic Tank or Holdinct Tank <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 pl ans. <br /> Plumber's Name(Print): Plumber's ignat :(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> ff Sc/m ;7`2 C 3)E f �g-ft3rg <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(includes a Feel water a e ssu Issuin g t Si at ( o S mps) <br /> Approved DOwner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/98) DISTRIBUTION: Original to county,One Copy To:Safety 8 Buildings Division,Ow er,Plumber <br />