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t-n <br /> SANITARY PERMIT APPLICATION <br /> �ME-" In accord with ILHR 83.05,Wis.Adm. Code co Nrr <br /> nQ <br /> STATE SANIT\ARY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than UU,JJpp ZZ( <br /> 8'h x 11 inches in size. <br /> Check if revision to previous application <br /> -See reverse side for instructions for completing this application. _5T-ATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> /lAnJo� Fob �E s A)6114 SW '/4, SAz? T3e, N, R E (or)® <br /> PROPERTY OWNER'S MAILING ADgpE$S LOT# BLOC # <br /> ,{I a// — <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 5/r�N w, 871 us-s��a <br /> II. TYPE OF BUILDING: (Check one) ❑State Owned O VILLAGE IS <br /> ❑ NEAR ST ROAD <br /> (p� D�¢N/e. <br /> Public I/�1or2Fam. Dwelling-#of bedrooms PAR ELTAX NUMBERS) <br /> III. BUILDING USE: (If building type is public,check all that apply) ��-d ,- 10 <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 ❑ Res aurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Ser ice 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 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 2.ABSORP.AREA 13.ABSORP.AREA 4, LOADING RATE 5. PERC. RATE 6. YSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Mi`ndinch) ELEVATION <br /> 5U b � Y8 , /4 y Feet y7, 3 Feet <br /> VII. TANK CAPACITY <br /> in allons Total #of Site <br /> INFORMATION Manufacturer's Name Prefab. Con- feel Fiber- Plastic Exper. <br /> New Tanks <br /> Gallons Tanks Concrete lass <br /> Tanks Tanks strutted 9 App- <br /> Septic <br /> PPSe tic Tank or Holdin Tank <br /> Lia Pump 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) / No.: Business Phone Number: <br /> ���/ <br /> Plumbbe�r's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agen Signatu No tamps) <br /> Approved ❑ Owner Given Initial }�y�, Surch rgo Fee) <br /> Adverse Determination 'r` Is�g <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br />— SBD=6398(R.OB/93) DISTRIBUTION: Original to County,One Copy To:Safety Buildings Division,Owner Plumber <br />