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�HR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE NRAR�RMIT#/moo,'?{ ) <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �' 'l <br /> 8%x 11 inches in size. ❑ Chock if revls to previous application <br /> --See reverse side for Instructions for completing this application. TATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. `-;L <br /> PROPERTY OWNER ! PROPERTY LOCATION <br /> I(J rg q-3oE-t G n d i it cCJ'/a I� 1/4,S3� T N, R &l E (Ori <br /> PROPERTY OWNER'S M.AILING ADDRESS LOT# r" BLOCK# <br /> ^ <br /> CITY STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> rho Iclkt' ", C; &,360 AP <br /> II. TYPE OF BUILDING: (Check one ❑State Owned CITY VILLAGE / / NEAREST ROADION Q91 D / <br /> �16� d Cl< LYI•?(ry�j' M1 <br /> ❑ Public Ni or 2 Fam.Dwelling-#of bedrooms A UM ER( ) <br /> III. 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 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranVBar/Dining <br /> 4 ElChurch/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 /> 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41Holding Tank <br /> 12 ❑ Seepage Trench 22 [1In-Ground42 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 16. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Feet Feet <br /> VII. TANK CAPACITY Site <br /> in Ilons Total #01 Prefab. Fiber- Exper. <br /> INFORMATION New ietin Gallons Tanks Manufacturer's Name ncret Con- Steel glass Plastic App <br /> strucled <br /> Tanks I Tanks <br /> Septic Tank o6old Ina Ta iji,e-se lrv1C <br /> Lift Pump Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for In tallation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Pr' j: Plum is Signature:(N s) MP/MPRSW No.: Business Phone Number: <br /> Plums is Address(Street..C tate.Zip Code): A.`eL <br /> IX. OUNYTYIDEPAR ENT USE ONLY <br /> Disapproved I Sanitary Permit Fee preludes Groundwater a esu Issuing gent Signature(No Stamps) <br /> 3urcherpe Fw) 1 � <br /> Approved ❑ Owner Given Initial jrl:•U�) q_!O_�/ <br /> Adverse rmi tion`// �J <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-63M(formerly PIb-87)(R.11/58) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />