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�. SANITARY PERMIT APPLICATION COUNTY <br /> DILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> p��• �_ STATE SANITARYRMIT#JIY <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ � V <br /> 81/2x 11 inches in size. c k If revisio 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 /> t- ✓d ki 5 o n Al 4d '/4 sec 1/4, S 3 T 3 7 N, R / E (or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> X - / C Q f 'd U 114 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned O VILLAGE KU r/� <br /> NEAREST ROAD <br /> ffCCI 0 <br /> ❑ Public 2 1 or 2 Fam.Dwelling-#of bedrooms 3 PARCEL TAX NUM K( <br /> III. BUILDING USE: (If building type is public,check all that apply) -Ji�J_ Off_ <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 ❑ Otfice/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 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 ElMound 30 ❑ SpecityType 41 El HoldingTank <br /> 12 E 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 14. LCADINGRATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> u REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 7 2 0 90 0 , s` < .� '� "SFeet 9 U Feet <br /> VII. TANK CAPACITY Site <br /> ingallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or HoldinTank ad o /09� ✓ <br /> Lift 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 plans. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> r r L- e/• ,� - d b - J <br /> Plumber's drew(Street,City,State,Zip Code <br /> L—✓, j [r / <br /> X. COUNTYIDEPARTIMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee (includes Groundwater Datessue Issuing Agent (gnat e(N m ) <br /> Approved ❑ Owner Given Initial H} Surcharge Fee) [x; <br /> Adverse Determination '�'1 I� • /� �� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety8 Buildings Division,Owner,Plumber <br />