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SANITARY PERMIT APPLICATION <br /> 70ILHR In accord with ILHR 83.05,Wis.Adm.Code cQWT Yn -'- <br /> • �- NITA PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less thanSTATE j �I <br /> 8'f x 11 inches in size. ❑ c eck if reel n 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. !a -,;- C� I <br /> PROPERTY OWNER PROPERTY LOCATION pp� <br /> L / cSR�v '7% s, S T.�a �, N, R /K9 W� r <br /> PROPERTY OWNER'Sk�AILIyG DDRESS - LOT# BLOCK# <br /> CITY,STATE ZIP CODE I PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> �V0 S 5 loci - <br /> II. TYPE OF BUILDING: (Check one) CITY �p NEAREST ROAD <br /> State Owned VILLAGE: Wood �F1V? P. <br /> ❑ Public 1 or 2 Fam.Dwellings of bedroomsN CL <br /> N I fMB R( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) - j0 J-- C� <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. 0 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 ERMound 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 DAI 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPP� 5-v)OSED(sq.ft.) (Gals/day/sq.ft.) ,((Min,.//inch))/ ELEVATION <br /> Soo an v - 7 /00. 7 Feet W [ <br /> , r-] Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Ten rtioldin Tank 000 <br /> Lift um Tan i hon Chamber a <br /> VII . ESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for)nstallation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plu ber's S' nature:( St ps) MP/MPRSW No.: Business Phone Number: <br /> Ale ht-? 71T Eta 6 <br /> Plumber's7f�/SAddress(Siree�I ,State,Zip Coda): <br /> IX. UN /D PARTMENT USE ONLY 6 <br /> ❑ Disapproved Sanitary Permit Fee(Isurcharge Groundwater a IssuedIssuing lent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial yi m 1 11,70 ) � ��4, �&,Ja,) t��"`)0�1� <br /> Adverse Determination -1V �J i�l �Q�! l <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 />