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1 SANITARY PERMIT APPLICATION �� ) ��'��A --, <br /> aN� In accord with ILHR 83.05,Wis.Adm.Code CO2 & <br /> STATE SPLNITARY PEEEPIMIT# <br /> ;tach complete plans(to the county copy only)for the system,on paper not less than ��ofo-77 ) <br /> 8%X11inches Insize. CheckIfrevision <br /> ❑ 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 /> �J 4 C 4/ �-1/a A/k"14,S 'd T//6 , N, R /4 <br /> PROPERTY OWNER'S MAILING ADDRESS /.r�-'/// LOT# / / BLOCK# <br /> LI <br /> CITU,STATEZIP CODE PHONE NUMBER SUBDIVISI N NAME OR CSM NUMBER <br /> a 7/f 35 l6 /�/Ic t/e.v� <br /> It. TYPE OF BUILDING: (Check one) ❑State Owned TY a <br /> C GE: d NEARES/ AID//�� <br /> /11 Or <br /> ❑ Public �1 or 2 Fam. Dwelling,#of bedrooms PARCEL TAX NUMBER( <br /> 111. BUILDING USE: (If building type is public,check all that apply) �-- 1©� <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 B if applicable) <br /> A) 1. ❑ New 2. 4 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 ElMound 30 ❑ Specify Type 41 ElHolding Tank <br /> 12 K 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.GALL(&SPER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> Jam( (/lj REOUI QED q.ft.) PROPO0D1(sq.ft.) (Gals day/sg.tt.) (Min./inch) VfjIQ N <br /> (/ V • S Feet fJYffeet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name refa t Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdina Tank BOO <br /> Lift Pump Tank/Siphon Chamber 0 <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): Pi u is Signature:(90 stomps) _ MP/MPRSW No.: Business Phone Number: <br /> !121-e ii 30-77 <br /> Plumj2er'p Addre treat,City,State,Zip Code): <br /> 277 /A /c ON,4 is C <br /> COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date ssu Issuing Agen S' ature o <br /> 'l, Surcharge Fee) <br /> pproved ❑ Owner Given Initial q� ' • OT —/S <br /> Adverse Determination fit' 0 <br /> CO DITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />