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SANITARY PERMIT APPLICATION <br /> EM,LHR In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> ru rY��_/_/ <br /> �• STATE/SA, NITARY PERMIT#,,1G)g3 <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ❑ l 1-W O <br /> 8%x 11 Inches In size. Check If revs n to 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 OWNPROPERTY LOCATION <br /> E#t 6 ,% 'S Lll'/SGYa,Saq TW , N, R (S-E{or WD <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> Q) tea! <br /> CITY,STATE , ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 1 Sf 3 <br /> II. TYPE OF BUILDING: (Check one) CITYrZ TOWN NEAREST ROAD (� / <br /> l�I State ❑ VILLAGES i SS 14Ke �� �a4d <br /> ❑ Public M 1 or 2 Fam.Dwelling-#of bedroomsa- A TAX M^�E <br /> 111. BUILDING USE: (If building type is public,check all that apply) � 621a —Q/ —0f)c <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. ❑ 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 ❑ 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,ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min..//inch) ELEVATION <br /> 300 y$>7 q O 0 e 6� Y— (71. 3-3 Feet ,S' Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New Istin Gallons Tanks Manufacturer's Name oncrate Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Ta or Holding Tank I <br /> LIN Pump Tank/Sf hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility f r Installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): PI ber's Signatur :( Stempa) MP/MPRSW No.: Business Phone Number: <br /> Ajp(& �v r S?8� ( 7/5- ) �6 P <br /> Plumber's Address(Stfeet,City,State,Zip Code): <br /> 7 Q <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Lj Disapproved Sanitary Permit Fee(Includes Groundwater Dale IssuedIssuing Ape SI store o Ste s <br /> Approved ❑ Owner Given Initial - �35 C� Suro^ergs Fee) <br /> Adve rmination <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 />