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7fflDILHR SANITARY PERMIT APPLICATION COUNTY R„ ^� <br /> In accord with ILHR 83.05,Wis.Adm.Code )E . <br /> STATE SANITAR^Kp`ERMIT I96AC <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ j qa 4�/ <br /> 8'%x 11 inches in size. ack If revlslroofiff to 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 /> PRO TY OW R PROPERTY LOCATION <br /> Q (�� '/a %,S 2 T N, R /S E (or <br /> PROP RTY O NER'S MAI ING ADDRESS LOT# BLOCK# <br /> oilfill) Aner -7/Y7 3 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM UMBER <br /> i tJ 3b 1 q2 • �t LAp V � <br /> II. TYPE O BUILDING: (Check one) CITY V NEAREST ROAD y� <br /> �.�7N� ❑State Owned VILLAGE 3kxSb rJ V yG.I�T r eI IC . <br /> ❑ Public J�SL1 or 2 Fam. Dwelling #of bedrooms L =11 R91 <br /> PARCEL TAX NUMBFRIS) <br /> III. BUILDING USE: (If building type is public,check all that apply) —"'1 scC)— cLl—XoD <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 ❑ RestauranUBar/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. TYIPPEE 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 /> 11Seepage Bed 21 ❑ Mound 30 ElSpecify 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 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals//day/sq.ft.) (Min./inch) ELEVATION <br /> Isp 2T0 2��� 112 (0- O Feet tj 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 /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon Chamber <br /> Vlll. 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 Sta pa) MP/MPRSW No.: Business Phone Number: <br /> Plumber's AddreSS 1&6,State.Zip Coder WEn� W)' SJ913 <br /> IX. COUNTYIDDEPIARTMENT USE ONLY <br /> 17 <br /> ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin nt Sig fur ( Stamps) <br /> Surcharge Feel <br /> Approved ❑ Owner Given Initial <br /> Adverse Determin tin —Ff' �J <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 />