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SANITARY PERMIT APPLICATION <br /> 7DILHR In accord with ILHR 83.05,Wis.Adm.Code couNTv <br /> c <br /> �M�•' STATE S/NITAR PERMIT <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8%x 11 inches in size. ❑ check If revlel 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 OWNER PROPERTY LOCATION T <br /> 1/4 1/a, S 23 T D, N, R I J E(or) <br /> PR LARI OWNER'S ML.AIL-'Z ACo DDRESS � LOT# IBLOCK <br /> LOCKK#ONERE (DS <br /> GTEZ� DEPHONE NUMBER SUBDIVISION OR CSM <br /> QEIINUMBER Add, JL �c, LA Li <br /> f V 1 <br /> It. TYPE OF UILDING: (Check one) 1:1 State Owned VILLLLAGE � T R l GAD <br /> ❑ Public A or 2 Fam. Dwelling,#of bedrooms— ( ) 1J�7 <br /> III. BUILDING USE: (If building type is public,check all that apply) la—�aco — <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. L1Replacement 3. ❑ Replacement of 4. ElReconnection 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 /> 11Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ElHolding Tank <br /> 12 19 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 PE77 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 3v REQUIR,f D(sq.ft.) PRO OQSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Q ELEVATION <br /> O p 1 11 •0 Feet 100 Feet <br /> VII. TANK CAPACITY Site <br /> in alions Total #of Prefab. Fiber- Exper. <br /> INFORMATION <br /> New istin Gallons Tanks Manufacturer's Name ConcreteCon- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank EC <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:(N Ste ps) MP/MPRSW No.: Business Phone Number: <br /> 1cogo oklus 1 c is -W) , <br /> umber's,AAArass(Street, vV state,Zip Code. W 6J \"` .w) . S4 <br /> X. COULLN..T�rtYr/+111DrEOOPART1LMl1ENT SE ONLY <br /> ❑ Disapproved Permit Fee(Includes Groundwater ate IssuedIssuing ntS natur o Stamps) <br /> Approved EJ Owner Given Initial /T�Surcharge Fee) <br /> 31 <br /> Adverse Determination <br /> et rmin I jSannary, <br /> - l3"s �—� ITA& - <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />