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SANITARY PERMIT APPLICATION <br /> aL IR In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> — $urn e-� l'- n <br /> �ry�• � STATE SANITARY P.&RMIT#a/ 3 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than -/����..tt���yyippJ\°) <br /> 8'%x11inches insize. ❑ ec <br /> Chk ifrevialon previous application <br /> -See reverse side for instrLictions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. S?Vn;0/0 <br /> P PEATY OWNER PROPERTY LOCATION <br /> ?3fl W % N�✓'/4, S 33 T VO , N, R <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> El 11. TYPE OF BUILDING: ( heck one) ❑State Owned VILLAGE: NEAREST AROAD ,r' <br /> {� O4 k� S <br /> K� Public ❑tor Fam. Dwellin"ofbedrooms— PARCEL TAXW.M_,_, <br /> Ill. BUILDING USE: (If buil Jing type is public,check all that apply) 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. N 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: (C tack only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 a� Seepage Bed 21 El 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. BSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> ! RE UIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch)_ q ELEVATION <br /> { /1© /o�`� cP700 � p <br /> .S ! /• S' Feet /s Feet <br /> VII. TANK CAPACITY Site <br /> ingallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name ConcreteCon- Steel glass Plastic App <br /> Tanks I Tanks structed <br /> sticT k:or Holdino Tank U= DO Wieser <br /> 6-ft—PumpTank/Si hon Chambe <br /> Vlll. 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): PI ber's Signat re: Stamps) MP/MPRSW No.: Business Phone Number: <br /> N-& Q-er _f_� <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTYIDEPARTME14T USE ONLY <br /> Lj Disapproved iSanitary Permit Fee(Includes Groundwater FU-atelesued I uing ants r (No Stamps) <br /> Approved ❑ Owner Giv nlnitial Suronarge Fee) cl <br /> A D termin tin 15O r L)� <br /> X. CONDITIONS OF APPF OVAL/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 />