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DIr.HR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code _Burn <br /> • STATE SANITA Y PERMIT 41S13-7;1_, <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ fs1(+I <br /> 834 x 11 inches in size. eck if rev4n 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 /> PROPERTY OWNS TrC_ <br /> OII LOCyTION <br /> 1/4, S � TSKJ, N, R /J E(or <br /> PROPERTY OWN R'S MAI ING 9➢DREss�sT# BLOCK#ZIP C PHI�NE NUMBERBDIVISION NAME OR CSM NUMBER <br /> II. TYYPE OF BUILDIING: (Check one) /7El CITY . NE REST ROAD <br /> ❑State OwnedVILLAGE <br /> [] public 01 or 2 Fam. Dwelling—#of bedrooms L TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) is - a�a- �a - 3co <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: (Checkonlyone in line A. Check line B if applicable) <br /> A) 1. El New 2. N 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 ❑ 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 /> V1. 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 /> REQUIRE (sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./int ) ^/ VA_TION <br /> 300 L /O O 7 �// Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total III of <br /> Prefab. Fiber- Expp. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks <br /> strutted <br /> Se tic Tank or Holdin Tank <br /> Lift Pump Tank/Siphon Chamber <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): Plumber's Signature:(No ps) MP/MPRSW No.: Business Phone Number: <br /> hrxf <br /> Plum is Address(Street,City,Stgte,Zip Code): <br /> �C'/ C c/I Jif <br /> X. COUNTY/DEPARTMENT USE ONLY <br /> E] Disapproved SanitryPermiIFee(IncludesGroundwater [Date Issuin ant n oStamps) <br /> �C)C- �surcharge Fee) <br /> Approved ❑ owner Given Initial <br /> AdverseDeterminaton <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb87)(R.11/98) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />