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SANITARY PERMIT APPLICATION <br /> DIS. IR In accord with ILHR 83.05,Wis.Adm.Code couNTv <br /> — BunnetZ /n! <br /> • � STATESANITARY RMIT#a��/a, <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than � M6:09) <br /> 8%x 11 inches in size. ❑ c heck if revisiopok,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. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> '/4 NE '/4,S 11 T39 N, R 77 (or)W <br /> PROPERTY OWNER'S MAILING A DORESS LOT# BLOCK# <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> CITY : J / 1 NEAREST ROAD <br /> If. TYPE OF BUILDING: (C ack one) <br /> El state Owned VILLAGE L ii L o i 0 <br /> ❑ Public Vq1 or Fam.Dwelling-#of bedrooms 2 ( ) <br /> III. BUILDING USE: (If buil ling type is public,check all that apply) 1(4-3L411-01- 010 <br /> 1 ❑ Apt/Condo <br /> 2 El AssemblyHall 6 El 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: (Chick 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 Perm t was previously issued. Permit# __ Date Issued <br /> V. TYPE OF SYSTEM: (C eck only one) <br /> Non-Pressurized Distrib ition Pressurized Distribution Experimental Other <br /> 11 Seepage Bed 21 ❑ Mound 30 ❑ 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 2. BSORP.AREA 3.ABSORP.AREA4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.h.) PROPOSED(sq.ft.) (Gals/day/sq.h.) (Min./inch) ELEVATION <br /> en 0 �8� � � -> yj" 6 Feet y$. Feet <br /> VII. TANK CAPACITY Site <br /> in gallons 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 1 _5 Kit <br /> cj <br /> Lia Pum Tank/SI hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume iesponsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:(No S ) MP/MPRSW No.: Business Phone Number: <br /> /�'> 0 �uF5 o/»n �L ��7��- �� N/ pis 3v9-7a86 <br /> Plumber's Address(Street,City, tate,Zip Code): <br /> .CSO _�- -�—L S//' �v`7 LU .�Y�7,;L <br /> IX. COUNTY/DEPARTME T USE ONLY <br /> Disapprove0 ISanitary Permit Fee(Includes aroundwater ate Issued Ise gent Signature(No Stamps) <br /> A I Approved ❑ Owner Giv ninitial (�'"surcharge Fee) L/ <br /> A D termin n � I�� o 7 <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 />