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(� uSANITARY PERMIT APPLICATION couN r <br /> U ��L IR In accord with ILHR 83.05,Wis.Adm.Code <br /> STATES NITARY PERMIT i����gr o <br /> -Attach complete plans(t the county copy only)for the system,on paper not less than �j 75c S)) / <br /> 81/2x 11 Inches in size. ElC k if revisiafto 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 PROPERTY LOCATION <br /> Y. Ys,S T qJAR E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT HBLOCKIll <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> a - )67,odd. ma Le& <br /> IJIF <br /> II. TYPE OF BUILDING: ( heck one) CITY � �lU NEAREST ROAD <br /> L]St8te Owned VILLAGE: '7 ,O <br /> ❑ Public U41 or 2 Fam. Dwelling-#of bedroomsPARCEL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) <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: (Ct eck only one in line A. Check line B if applicable) <br /> A) 1. ❑ New 2. X1 Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) ❑ A Sanitary PerrT it was previously issued. Permit# — Date Issued <br /> V. TYPE OF SYSTEM: (C heck 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 Trent 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. kBSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) p ELEVATION <br /> JV Zoo Z. 3 92 O Feet -D Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in gallons Total qof PreTab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdin Tank <br /> Lift Pump Tank/Siphon Chambe <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 tamps) MP/MPRSW No.: Business Phone Number: <br /> c o 3`'V,, 7(S $�� gjS7 <br /> PI mber's ddrese(StreeLCi Stete,Zip Code): <br /> 7,17 <br /> 0 3S r:BSfE K W 3 <br /> IX. CoUNTY/DEPARTME T SE ONLY <br /> ❑ Di9approv Sanitary Permit Fee(Includes Surchar Groundwater Date slue Isau g A ant Sign o Stamps) <br /> Approved <br /> Surcharge Fee) L <br /> ❑ Owner Gi n Initial 1 C I Q (! <br /> Adverse D i ���..11 X. CONDITIONS OF APPF OVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb87)(R.11 88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />