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17— m00% SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> �• STATE(�SANITARY PERMIT# ��C <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than l ( SC'3� \1 <br /> 8%x 11 inches in size. ❑ Check If revision to pr vious 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 /> -e q h t it 6 11 4e i ) .1 h4j)� %,S T , N, R It(0 W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> X- r u S ) 6 -17 I N Yf-G�0Vtcof- <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME R CSM NUMBER <br /> 11 CITY 8j) <br /> Ss � Irl l� <br /> It. TYPE OF BUILDING: (Check one) ❑State Owned 0 VILLAGE NEAREST ROAD !12 <br /> / <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms 3 PARCEL TAX NUMB <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo 7 <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. ENE 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 El SpecifyType 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 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) el ELEVATION <br /> f_r(U (o(� G t(If - �& r D_-- / 7 Feet �®/ Feet <br /> VII. TANK CAPACITY Site <br /> I <br /> allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank1 /000 W e <br /> 11 El +ar7 <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.: Business Phone Number: <br /> od Hck . t"Frn 6 9 5 YISI <br /> Plumber's Address(Street,City,State,Zip Code): <br /> W e. k_XJ­k a. . S Y <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee(includes Groundwater [DateIssued Isuln AgentSign (No Stamps) <br /> Approved ❑ Owner Given Initial (.,'OSurcharge Fee) <br /> Adverse Determination C <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 8 Buildings Division,Owner,Plumber <br />