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SANITARY PERMIT APPLICATION <br /> 7 DI&.HR <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> M~ �_ STATES ITAR ERMIT#)3aj <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than (/LjrJ( <br /> 8%x 11 inches in size. ❑ Cheok if revisigh 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 <br /> M ( u '.ro X' ME 1/4 UE '/4,S 13 T 9Q N, R 7 E (o W <br /> PROPE OWNER'S MAILING ADDRESS LOT# 3 BLOCK#� <br /> e,h• <br /> CITY,STATZIP CODE PHONE NUMBER SUBDIVIS� Il1Nf•!A E OR CSM NUMBER _ <br /> MlNkt /e4k Mh• SS3ys 3 -J7 <br /> If. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ❑ State Owned VILLAGE Y h` d <br /> ❑ Public [)1 1 or 2 Fam. Dwelling-#of bedrooms a` PARCELAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) �r 0'!l_ I _ <br /> 1 ❑ Apt/Condo sJ r <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. Q 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 PERDAY 2.ABSORP.AREA 3.ABSORP.AREA 4. 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 /> 3 eo 1410 1 y3 a . 6 9 Y 9�1: Feet 1408. 1 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank I rKn I 7S' M <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:(No Stamps) MP/MPRSW No.: y( -7, /-1- <br /> iness Phone Number//::/ <br /> rl . S 666-71 <br /> Plumber's Address(Street,city,State,Zip Code): <br /> W %-eS r wt <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sani ry Permit Fee(Includes Groundwater a e sue v Issui gent SigneNo Stamps) <br /> pproved ❑ Owner Given Initial 1 0SSurcharge Fee) <br /> a 3 0 <br /> Adverse Determination <br /> X. CONDITIONS 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 />