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S SANITARY PERMIT APPLICATION <br /> iiCO N <br /> Ins T'Y} <br /> In accord with ILHR 83.05,Wis.Adm.Code i 1Ju rn� <br /> ST TE SANITARY PERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than / `Q�$47C <br /> Elx 11 inches in size. La)�ifr­l "` <br /> 4alc 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. <br /> PROPE WNER PROPERTY LOCATION <br /> t A 6/ %3/ /a, S 33 T Q �, N, R E(or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLO # <br /> / <br /> CITU,STATE ` ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> II. TYPE OF BUILDING: (Check one) Cl NEA EST ROAD <br /> ❑ State Owned ❑ VILLAGE: �� � 0 3 <br /> Public �or 2 Fam. Dwelling #of bedroom ARCEL TAX NUMBER( ) /C <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo I <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. ew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> S stem 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 Xeepage Bed 21 ❑ Mound 30 L1 SpecifyType 41 El HoldingTank <br /> 12 ❑ Seepage Trench 22 ❑ In-Ground 42 El 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 12.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED F(sq� .ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) q /� ELEVATION <br /> 41�3 <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 Holdin Tank v <br /> Lift Pum Tank/Siphon Chamber. <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached lans. <br /> Plu er's Name(Print): Plum Ign re: o Stam MP/MPRSW No.: Business Phone Number: <br /> N 1� E• 9t iO 0 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> � 7 3 �3v� uJ � <br /> IX. COUNTY/DEPARTMEN USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Iss g A nt Sign r (No Stamps) <br /> Approved E] Owner Given initial I oc�.�rcl�/,.G� <br /> Adverse Determination largo Feel <br /> v`J Su (/ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety B Buildings Division,Ow er,Plumber <br />