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SANITARY PERMIT APPLICATION COUNTY <br /> aDILHR In accord with ILHR 83.05,Wis.Adm.Code RU rnebt::7– p <br /> �M STATES NITARYP MIT#,?())SCIS <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than (g)–r--3 3 8'%x 11 inches in size. ❑ Check if revision t6 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 OWNERP OPERTY LOCATION <br /> a-ppN vJ %5E 11.,s7_4 T N, R E(o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> CITY,STATE I ZIP CODE` I PHONE NUMBER 7 S OEM <br /> Wil- S 15 `I <br /> It. TYPE OF BUILDING: (Check one) ❑State Owned VILLAGE C� NEA EST ROAD <br /> coir <br /> [11 Public K1 or 2 Fam. Dwelling–#of bedrooms 3— A N <br /> III. BUILDING USE: (If building type is public,check all that apply) o29-4)a I-0 3-600 <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 E-1 Medical Facility/Nursing Home 10 1:1 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. TYPPE{{{OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. l�1 New 2. El Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.El 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 N Seepage Bed 21 ❑ Mound 30 El 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 12.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> d bZ JT .0 Feet - 0 Feet <br /> VII. TANK CAPACITY 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 /> Se tic Tank or Holdina Tank <br /> .Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,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 tamps) MP/MPRSW No.: Business Phone Number: <br /> t��iA OPKI SIS �+ � 3`4Z� �S 866- IS7 <br /> PI mber's Address(Street,City,State,Zip Code): EQp a <br /> 1 . <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a Issued Iss Agent Sign t re(No Stamps) <br /> ,y as.�surcharge Fee) <br /> pproved ❑ Owner Given Initial Wim( <br /> Adverse Determination <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 />