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i..� SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTY <br /> STAT! <br /> TAT SANITA RYPERMIT <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than � 0 $yIS <br /> 8%x 11 inches in size. ❑ Check if revision to previous application <br /> —See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPLLOCATIONTT , N, R 16 E (or)PROPERTY O NERS MAI 1 G ADDRESS LOT# BLOCK# <br /> CI ,STAT-E11 ` , ZIPCODE PHONE NUMBER SUBDICSM NU BER <br /> 00 A- Z <br /> It. TYPE OF BUILDING: (Check one) 171 CITY NEAREST ROAD <br /> State Owned VILLAGE:O Ia, Ef1$rCD <br /> ❑ Public �10r2Fem. Dwelling #of bedrooms Z A EL TAX LQLNUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ ApVCondo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranVBar/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. K 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 [1Mound 30 ❑ Specify Type 41 El HoldingTank <br /> 12 6 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 14. LOADING RATE 5. PER' RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 3 OQ REO4� UIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.11. (Mindinch) p ELEVATION <br /> 12q r� lS ' Feet 900.0 Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank <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) MP/MPRSW No.: Business Phone Number: <br /> Iwo ?Xlz 3yZ6 71S J4 /S 1 <br /> Plumber's Address(Street,City,State,Zip Code' <br /> 2 1 e H4 35 514 W). AW <br /> IX. COUNTYIDEPARTMEN USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includea Groundwater ae ssue Issuin Agent Signatur IN Stam s) <br /> (A roved }}. _ �$prcharge Fee) <br /> pp ❑ Owner Given Initial y-) I�O ¢1L <br /> Adverse Determination f'1 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />