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DILNTY <br /> H I SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couS t <br /> — STATE SANITARY ERM IT <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 1-73A ) <br /> a0� I <br /> 8%x 11 inches in size. ❑ ChCk If revisig^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 /> PROPERTY OWNER LPRERY LOCATION <br /> ernvrd ?fr ,UttJ'i.,so� T3 N, R i E(or wPROPERTY OWNER'S MAILING ADDR SS BLOCK# <br /> 2 ISU hem D-/ ' <br /> CITY,STA�TE ZIP CODE PHONE NUMBER ON NAME OR CSM NUMBER <br /> SII. TYPE OF BUILDING: (Check one) NEARESTROAD <br /> State Owned GE❑ Public X1 or2Fam.Dwelling,#of bedroomsh UM <br /> III. BUILDING USE: (If building type is public,check all that apply) 34- sa y- o J— 6aC) <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. UN 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 PER DAY 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> �--/� REQUIRED(sq.ft.) I PROPOSED(sq.ft.) (Gals/day/sq.ft.) I (Min./inch) pELEVATION <br /> �J 7= L 0 1 -7-)-0 ,(v -QL-c�, si�0/ Y Feet /o7.S_ Feet <br /> VII. TANK CAPACITY I 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 /> CCT or Holdino Tank 60C2 ( tf <br /> Litt 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): PI bei a Signet e:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> e(s kln.,er WP S?1 66-LZicr <br /> Plumber%ddress(Street,City,State,Zip Code):`C r �' <br /> r <br /> _S I(Slet <br /> IX. COUNTYIDEPARTM T USE ONLY <br /> E] anita <br /> Disapproved Sry Permit Fee(Includes Groundwater ae esus Issui nt Signature(No Stamps) <br /> su <br /> Approved ElOwner Given Initial �rcnarpe Feel <br /> Adverse Det rmin n �� – <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Pib-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />