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(� SANITARY PERMIT APPLICATION COUNTY <br /> lJ oILHR In accord with ILHR 83.05,Wis.Adm. Code &rn a.L <br /> STATE SANITARY PERMIT# 12 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ( (L-i 4'3C) <br /> 8'%x 11 inches in size. ❑ Check if revision 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 /> PROPERTYOWNER _ PROPERTY LOCATION <br /> SE '/s.Su/ '/a, S TV,) , N, R E(or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> S C. 7_ 9�'� y'k. Lot b.� <br /> CITY,STAT ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> El It. TYPE OF BUILDING: (Check one CITY NEAREST ROAD <br /> State Owned v1L1 AGE <br /> L, -j<o.V u L <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms A L MBER( <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: (Check only one in line A. Check line B if applicable) <br /> A) 1. ❑ New 2. eplacement 3. ❑ Replacement of 4. ElReconnection of 5.❑ Repair of an <br /> System �Ilystem 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 I Seepage Bed 21 El Mound 30 ❑ Specify Type 41 F-1Holding 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 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./i ch) / /I ELEVATION <br /> 4_11qFeet UC»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 structed <br /> Septic Tank or Holdin Tank 7 <br /> Lift 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): Plum ature:( o Stam MP/MPRSW No.: Business Phone Number: <br /> Plu er's Address(Street,City,State,Zip Cade): <br /> IX. COUNTY/DEPARTMENT USE ONLY 1 17 <br /> ❑ Disapproved Sanitary Permit Fee includes Groundwater a is mue 1 1 Agent Si lure(No Stamps) <br /> surcharge Fee) <br /> El Approved F-1 Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/99) DISTRIBUTION: original to County,One Copy To:Safety 3 Buildings Division,Owner,Plumber <br />