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�- SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis. Adm. Code cou N <br /> `-[J- <br /> STA E SANIT Y PERMI � <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8%X 11 Inches In size. Check if revision o previous application <br /> -See reverse side for instructions for completing this application. sTA r <br /> E PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPE OyJNER PROPERTY LOCATION <br /> 4' �'/a 1 /a, S T,J�, N, R F1w) W <br /> PROPERTY O NER'S MAILIN D RE LOT# BLOC <br /> Ti¢t 4- <br /> TY, ATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBERS 1 <br /> 5r v _/ <br /> II. TYPE OF BUILDING: (Check one CITY NE ST ROAD <br /> ❑ State Owned VILLAGE : �(fj� `Al* <br /> [:] Public 1 or 2 Fam. Dwelling-#of bedrooms PA EL TAX NUMBEfl( ) <br /> Ill. BUILDING USE: (It building type is public,check all that apply) _j - <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Out oor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Re taurant/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. El Replacement 3. El Replacement of 4. EJ Reconnection of 5.El 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 /> 11Seepage Bed 21 ❑ Mound 30 El SpecityType 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 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6 SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 7 // QELEVA IION <br /> ZZ I Feet / Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holdin Tank <br /> -- F% <br /> Lift Pum Tank/Si hon Chamber Ej <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached lans. <br /> Plumber's Name(Print): Plumber's Si ature:(No tam ) MP/MPRSW No.: Business Phone Number: <br /> lumber's Address(Street,City,State,Zip Code)y:� / <br /> G�LZIry rig <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary P rmit Fee(Includes Groundwater [Date Issue Issuing gemsi natur ( o Sta pa) <br /> C�LApproved F71Owner Given Initial ' ( ,�ergo Fee) <br /> Adv rse Det rminalion !'" <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,O mer,Plumber <br />