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SANITARY PERMIT APPLICATION <br /> oa­1LHR In accord with ILHR 83.05,Wis.Adm.CodecouNTY RN _ <br /> STATE,SANITA14Y PERMIT#��a ` <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ <br /> 8%x 11 inches in size. � <br /> C eck if re on 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 OWNER PROPERTY LOCATION <br /> moete�rf% t%,S Z T O , N, R 1� E(or W <br /> PRO ER WN 'S MAILIN ADDRESSD LOT# BLOCK# <br /> • R� <br /> CITY,STATE ZIP CQDE PHONE NUMBER SU DIVISION NAME OR CSM NUMBER <br /> csm U. 93a in 6DV+-. <br /> II. TYPE OF UILDING: (Check one) CITY : �.7 N AREST ROAD <br /> ❑State Owned VILLAGE; NYv <br /> El Public 1 or 2 Fam.Dwelling-#of bedrooms NUMBER(S) <br /> 111. BUILDING USE: (If building type is public,check all that apply) � — <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.ElRepair 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 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> RE UIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/dd/aa�y/sq.ft.) (Mi ./inch ) �EJ�EVATION <br /> �Q ,b e &Z 9S. 7— Feet Feet <br /> VII. TANK CAPACITY Site <br /> in gallons 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 Holdino Tank <br /> Litt Pump Tank/Siphon Chamber, ^ C <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:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> leg4) '/% 11ePx1V!5 3`IZL ES Q /�/ � <br /> Plumber's Address(Street,City,State,Zip Code): <br /> _ 4 w 3 I�S(CK LJ1• �"`� <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee llncludes Groundwatera e IssuedIsau ant SI re(No Stamps) <br /> _ /-r—�Surcharge Fee) ^y] q3 , <br /> Approved ElOwnereDet Deteinitiarmination <br /> n ��S�w 10 � _ <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 8 Buildings Division,Owner,Plumber <br />