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SANITARY PERMIT APPLICATION WNUMBER <br /> MfiCiR In accord with ILHR 83.05,Wis.Adm.Code <br /> *% <br /> PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than a3trR88%x 11 Inches In size. on to previousapplication-See reverse side for instructions for completing this application. UMBER1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. O 0 <br /> PROPERTY OWNER PROPERTY LOCATION <br /> t/a /a, S / ry T , N, �/ E (or) <br /> PROPERTY OWN R'S MAILING AD RESS LOT# BLOCK# <br /> / a L 6,� NA <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> i S <br /> CITY NEAR ST ROAD <br /> 11. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLAGE <br /> ❑ Public ©1 or 2 Fam. Dwelling—#of bedrooms� PALE <br /> RCEL TAX NUMB RO <br /> 111. BUILDING USE: (If building type is public,check all that apply) �0 $ - All 1 -' 0/ — '/0 <br /> ' <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Out oor 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. El New 2. © Replacement 3. El Replacement of 4. ❑ Reconnection of 5.L1 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 Q 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 3.ABSORP.AREA 4. LOADING RATE 5. MRCi R hTE 6 SYSTEM ELEV. 7' ELEVATION <br /> GRADE FINAL <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) ( ) <br /> 3 �2 �_ Feet Feet <br /> VII. TANK CAPACITY Site Fiber- Exper. <br /> in allons Total #of Prefab. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> strutted <br /> Tanks Tanks <br /> rtic Tank or HoldingTank 0 O G a <br /> Pum Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached tans. <br /> Plumber's Signature:(No Stamps MP/MPRSW No.: Business Phone Number: <br /> Ore <br /> Plumber's Name(Print)/: g <br /> /// Q/S Cs L 6 J <br /> Plumber's Address(Street,Qt(StState,Zip Cod <br /> 1 1.3 <br /> IX. COUNTY/DEPARTMENT USE ONLY ssuing isi nat r ( S ps) <br /> Disapproved Sanitary P rmil Fee(ISurch11 1 ArmrFee)water a e Issued _ <br /> Approved ❑ Owner Given Initial lc . cCi' —I a'� <br /> Adverse Determin tion tl <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Set Division.0 ner,Plumber <br />