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mm"lSANITARY PERMIT APPLICATION <br /> UILHR In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> r <br /> STATE,SANI f�ERM1T#' /O <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than CC/ <br /> 8%x 11 inches in size. ❑ check it rev on to 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 /> P PERTYO OWNER jO ERTY TATION <br /> L-AllCj '/a 1£Ys, S T Q, N, R E (or W <br /> P OPEERRTY DWIJERR'S MAII gJG ADDRESS T# BLOCK# <br /> CITY,STATE MVS � ZIP ODE PH NE NUMBER BDIVI NAME OR CSM EII. TYPE OF BUILDING: (Check one) ❑State OwnedVILLAGEN ES7 ROA❑ Public W1or2Fam. Dwelling–#ofbedroomsR L I AxN t <br /> Ill. BUILDING USE: (If building type is public,check all that apply) J a-/') N <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.❑ New 2XReplacement 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 k5 1 Seepage Bed 21 ❑ Mound 30 El Specify Type 41 ❑ Holding Tank <br /> 121❑ 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 B1 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADINGRATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> ,�>C) R UIRED(sq.ft.) P P�IOS D(sq.ft.) (Gals/day/sq.ft.) (Min./inch) p► ELEV, ION <br /> � t 251 c , O Feet rJ Feet <br /> VII. TANK CAPACITY Site <br /> in 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 Tank <br /> Lift Pum Tank/SI hon Chamber El <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> P bar's Name(Print), P". pr's Signat :No mps) MP/MP W No Bus' ass Phone Number: <br /> Plu It s Add`as( rCity,State, ip C e): <br /> (0 W111 SLI V3 <br /> IX. POUNTYIDEPARTMENT USE ONLY <br /> Disapproved San�it.}ary Permit Fee(Includes Groundwater Date Issued Issuing Aggat Signatu a(No tamps) <br /> Approved ❑ Owner Given Initial y-{ /O� 0Tl�r6narge Fee) / /`S <br /> Adverse Determination —N ( lll� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-M(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />