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SANITARY PERMIT APPLICATION COUNTY <br /> 751LHR In accord with ILHR 83.05,Wis.Adm. Code-�— <br /> • �� STATE SANITAR ERMIT# 13-36-19-Attach complete plans(to the county copy only)for the system,on paper not less than ❑ LI� 11 <br /> 8'%x 11 inches in size. CLI, <br /> kIf revial 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. SS — aC r7 a,6 <br /> PROPERTY OWNERPROPERTY LOCATION <br /> WV S E '/4 .UF '/4,S 1T T y , N, R l(� 1 (o W <br /> PROPE TY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> CITY,STATE ` ZIP CODEPHONE NUMBER SUBDIVISION NAME OR CSM NUMBER _ <br /> 0Asa� C l4 <br /> It. TYPE O BUILDING: (Check one CITY NEA E$T ROAD <br /> ❑ State Owned O VILLAGE 52 TOWN :Sr <br /> Public ❑1 or 2 Fam. Dwelling-#of bedrooms— AR EL NUMB ) <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. ® Replacement 3. El Replacement of 4. El 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.Al3SORP..AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERI.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REOUIRED( q.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> � _0 (� Feet 1(�7 7 Feet <br /> VII. TANK CAPACITY Site <br /> in alit a Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank Od �-' <br /> L i hon C amber l�OO ) <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): Plu r 9 Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> �- a S clog- <br /> Plumber's <br /> A dr e (Street,City,State,Zip Code): <br /> r LA-"j . <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signature(No Stamps) <br /> Surcharge Fee) <br /> Approved ❑ Owner Glveemnin los-in <br /> Av trmin Ill Q <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD­6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />