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SANITARY PERMIT APPLICATION <br /> DJLHR In accord with ILHR 83.05,Wis.Adm. Code COUNTY <br /> —�"• tin <br /> STATE SANITAR PERMIT#ei7� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 0 l��IIJJ�� <br /> 8'%x11inches insize. ❑ Checklirevi on to previous application <br /> —See reverse side for Instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. S 90 0 "'17 <br /> PR PE TY OW ER PROPERTY LOCATION '/ <br /> f� 0 S EYaS '/a,S 3�oT7ON, R / E (or W <br /> PRWERTY OWNER'S MAILING ADDRESS LOT# ��� O BLOCK# <br /> >5" jC4;L 5 30 or ' <br /> CITY,STATE, , ZIP CODE PHONE NUMBER SUBDIVISION NPME OR CSM NUIt1BER <br /> / 7 rt nes <br /> 11. TYPE OF BUILDING: (Check one) ❑ State Owned CIT4GE NE?A EST ROAD <br /> u41l &VA <br /> C0lcorcn P� <br /> ❑ Public ❑1 or 2 Fam.Dwelling,#of bedrooms A <br /> III. 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.❑ 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 /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> �/ REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> ( Sa 37S-S- 3 1-"/>7 ' r- Feet 10 J Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xtstin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> (9e,ticTanIA,H,Idina Tank Vonc I I tA11r,_S,-r e" P <br /> Pum nk/Si hon 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): PIu bar's Signatur :(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> e(S , �, � 1?q!� S7�`f i Sd� <br /> Plumber's Address(Sir t,City,State,Zip Code): <br /> Y_ C Uw <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwatera e ssue issuing-Agent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial ��'J0 /-^ Surcharge Fee) /— n' <br /> Adverse Det rmin i n / UU / 7 C7/1O wz/ ci <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/98) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />