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SANITARY PERMIT APPLICATION <br /> HR In accord with ILHR 83.05,Wis.Adm.Code couNTv <br /> D,�,L <br /> �• �_ STATE SANITARY PERMIT Ill ,3L <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than 0 1 `j 5 oG <br /> 8'%x 11 IDChes In size. ❑ Check if revision to previous application <br /> -See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. 5$9-ZO L <br /> PROPERTY OWNER PF�PpPERTY LOUV IV`CCATION <br /> 0 � nkn �rGf 1YgFAg '/a,S a T 4, N, R E (o W <br /> PROPERTY OWNER'S MAILING ADDRESSLOT# BLOCK# , r <br /> 1 1 n! 14 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER/ y� <br /> k� / / d '` V . � ° all <br /> It. TYPE OF UILDING: (Check one) CITY NEAREST ROAD <br /> ❑ State Owned VILLAGE Q Y <br /> G <br /> ❑ Public 1 or 2 Fam. Dwelling–#of bedrooms A AX NUMBER fyy1�;9y�, <br /> III. BUILDING USE: (If building type is public,check all that apply) �Jo�.C�- 43 '>??q— <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. V 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 ❑ Specity Type 41 R 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 13.ABSORP.AREA 14. 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 allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name ConcreteCon- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank orHoldin Tank L90C C <br /> Lift 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 Stamps) M/P//MPRSW No.,.: Business Phone Number: <br /> OV's-VP(C t T li� O3 / 7, S- L <br /> Plumber's Ad as(Streer�t,'�City,State,Zip Code): <br /> ' �y SS <br /> W V� � O S <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved San' ry Permit Fes(includes Groundwater ae ssue Issuin Agent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial //Y- <br /> surcharge l=ee) Q q <br /> Adverse termin i ���--IYY' ((,JJ5 60 `-' 1$ � <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />