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FZED1jL,H"R SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY A It__77_ <br /> STATE SANITARY �v MIT#/n,;�3(� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �/ / <br /> 8%X 11 IDCh83 In size. ❑ Check if revision 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 �7 v �/ <br /> ^V 4 t%, S2p T (J , N, R �� E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> t3 o x S `I1 -7 <br /> CITY,STATE ZIP ODE PyONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> AIJ u� �Nl 3t IMM7890 s IsT o. D i36V <br /> II. TYPE OF WILDING: (Check one) CITY NEAREST <br /> RRO <br /> State Owned VILLAGE S W t s s !+'ray'"-12 ST__ <br /> ❑ Public �1 or 2 Fam. Dwelling–#of bedrooms 2 l C Z_K <br /> 111. BUILDING USE: (If building type is public,check all that apply) 3;�_014_75—'DL--' VM <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. ElReplacement 3. El 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 M Seepage Bed 21 ❑ Mound 30 El SpecifyType 41 El 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 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 3 aO REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch aELEVATION <br /> 00 r (P1 J Feet 17. qFeet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdina Tank 11 <br /> Lift Pum Tank/ i 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) MP/MPRSW No.: Business Phone Number: <br /> ICHRIZD FK/tj5 2� 342 +5" Sk- 5 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> ` -1 too Htj4 �35 wE► 5TS EK <br /> X. OUNTYI PARTMEWT USE ONLY <br /> Disapproved San' Permit Fee(includes Groundwater ae esus issuing o e s) <br /> 105 Surcharge Fee) l8 <br /> Approved ❑ Owner Given Initial <br /> Adverse Determination � <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />