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SANITARY PERMIT APPLICATION <br /> UWE 0ILHR In accord with ILHR 83.05,Wis.Adm.Code couNTY &- <br /> )T-STATE SA TARP ERMIT#01(833 <br /> -Attach complete plans(to the county copy only)for the system,an paper not less than ���r O <br /> 8%x 11 inches in size. ❑Check If revia 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. <br /> PROPF,RTY OWNER PROPERTY LOCATION <br /> C 5J '/4<jj Ys,S T N, R1( E (o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 2_1q70 W , co& cx • go . <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> It. TYPE OF BUILDI : (Check one El <br /> CITY NEAREST ROAD <br /> ❑State Owned ITY N AF t/, 9,0 /NE <br /> El Public 1 or 2 Fam. Dwellings of bedroom L U <br /> III. BUILDING USE: (If building type is public,check all that apply) a� - y335— O(..�- <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 ��SSystem 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 /> 11Seepage Bed 21 El Mound 30 ❑ Specify Type 41 El 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 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.h.) PROPOSSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) n ELEVATION <br /> G-� ZD to Z_ 3 90- Feet 3 .. Feet <br /> VII. TANK CAPACITY Site <br /> INFORMATION in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> New istin Gallons Tanks oncret strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holdin Tank 000 <br /> Lift Pump Tank/Siphon 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): Plumber's Signature:( S pill MP/MPRSW No.: I Business Phone Number: <br /> L7/S-)94- 4(51 <br /> lumbersddress(Street,City,St ,zip Code <br /> Z 7(e- In ) . $t3 <br /> IX. COUNTY/DEPARTMENT USEIONLY <br /> Lj Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Ag natur (No pa) <br /> Approved ❑ Owner Given Initial Suharge Fee) <br /> Adverse D <br /> Determination e coVU _ <br /> X. dONDITIONS OF APPROVAL/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 />