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4 SANITARY PERMIT APPLICATION <br /> 751HR In accord with ILHR 83.05,Wis.Adm. Code c( r <br /> urne <br /> STATE SANITARYP MIT#)alt8Sa <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than CC t� <br /> 8'%x 11 inches in size. ❑ ChecklIf revielon o 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 /> P PERTY OWN R PROPERTY LOCATION <br /> L �L 7 o rse 744 (.41'/.5Lt t/a, S 2-V T V0, N, R / E(or <br /> PROPERTY OWNER'S MAILIN(.AD9RESS LOT#( 3 �/ I BLOCK 11 <br /> SS r / t4-ve t <br /> CITY,STATE ZIP CODE PHONE NUMBER SUB.VISION NAME OR CSM NUMBER <br /> r re > 'Far,K IA4d _ <br /> II. TYPE OF BUILDING: (Check one) clTv : NEAREST ROAD <br /> ❑ State Owned 22 VILLAGE: SGQ f Co U7 1 <br /> QE <br /> ❑ Public X 1 or 2 Fam. Dwelling-#of bedrooms L AX NU ) f d <br /> III. BUILDING USE: (If building type is public,check all that apply) 9c)-75-- oa 30a <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. 1�9 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 El HoldingTank <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. PER'.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> /� REOUIRED(sq.ft.) PROPOSED(sq.ft.) (Gal /day/sq.tt.) r(�Mindinch) C� ELEVATION <br /> -i , 1/ (P L S (,.� 1. '!- `�3- /b.-] Feet 2 3, 7 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Profab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank ( ) Wt�$er C <br /> Lift Pum Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for i foliation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumb is Signre:(No S ) MP/MPRSW No.: Business Phone Number: <br /> (S Q e 2 l21 P S78 L/ 7� ?(126- <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Z tt <br /> COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Signature(No Stamps) <br /> Approved ❑ Owner Given initial <U I/\� q,i'1 surcharge Fee) J rXJv{f(/ �oap <br /> Advrmin t X1.1 IU °(,IIJ <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-07)(R.11/89) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />