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SANITARY PERMIT APPLICATION couNTY <br /> OILHR In accord with ILHR 83.05,Wis.Adm.Code R f p <br /> STATE PNITARY P RMIT#p�O-j tE <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than (/ IImo( /C! Y <br /> 8'%x 11 inches In size. ❑ cL(irevisio 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 P OPERTY LOCATION /� / <br /> '�a N L %,S 3Z T Q N, R IG E(Or) <br /> PROPERTY WNER'S MAILING ADDRESS LOT# r_ BLOCK# <br /> IST (0 <br /> CITY,STATE //.. 71P.CODE PHONE NUMBER SUB TY <br /> NAME OR CSM NUMBER <br /> P U)r L�OD Ca 6 EMAM <br /> It. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ❑State Owned VILLAGENNOF ".1 <br /> U Q.Q� �•-�,,,, <br /> ❑ Public K1or2Fam. Dwelling-#ofbedrooms— R EL TAX NU S) y� /-�!� <br /> III. BUILDING USE: (If building type is public,check all that apply) �C) � <br /> '-� 0 —OR—E'J00 <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. ❑ 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 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. PERI.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REOU RED AREA <br /> ft.) PROPOSED(sq.ft.) (Galls/day/sq.fl (Min./inch) q5. QELEVATION <br /> 3�(� a 6 Feet "I O • Feet <br /> VII. TANK CAPACITY Site <br /> in a110 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 Holdin Tank " / �. <br /> Lift Pum Tank/SI hon 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): e 1 Plumbee 'a Signature:(No mps) MP/MPRSW No.: Business Phone Number:[ <br /> Plumber's Address(Street,City,State,Zip Code): <br /> to b H w( - bi <br /> IX. COUNTYIDEPARTMEN USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater <br /> IDatee I IssuedQU� Issuing A ant SignaturCe./(NYo'1Stqami-p� <br /> s) <br /> Approved ❑ OwnereSurcharge Fe ) <br /> Adverse DeterminF1 v <br /> 1(M- <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />