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SANITARY PERMIT APPLICATION COUNTY <br /> �DIL <br /> IR. In accord with ILHR 83.05,Wis.Adm.Code f.LL <br /> — Bee rl'le'rT� <br /> .e....,,a� STATE SANITARY PE MIT#/ <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than /(//� 5 o-1(U� F l <br /> 8%x 11 inches in size. ❑ Check'8 revlslon t revious application <br /> -See reverse side for instructions for completing this application. s ATE PLAN I.D.NU BER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. V - ���� <br /> PROPERTY OWNER PROPERTY LOCATION <br /> 1 F 5 t?ca �k+ �hvrc:tt e d v n I ''. 'j td/., S T3?, N, R ALW) <br /> PROPER4k Ka 70 <br /> TY OWNEry'S MAILIN DPRESS LOT# BLOCK# <br /> 1 1 <br /> CITY,STATE ZIP CODE PHONE NUMBER - SUBDIVISION NAME OR CSM NUMBER <br /> S 1 rP�t, l c�tl 5 87� 7if I <br /> 11. TYPE OF BUILDING: Check one CITY '{'� NEgR T ROAD ; <br /> ( ) ❑State Owned •� ❑ VILLAGE TnwN :j/dfd f a is S' �d 7 <br /> ❑ Public X 1 or 2 Fam. Dwelling-#of bedroom-j-- PARCEL TAX NUMBERJSJ <br /> / rv� <br /> 111. BUILDING USE: (If building type is public,check all that apply) �—��q_ 0�—6co <br /> 1 ❑ ApVCondo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranUBar/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. JZNJ 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 M Mound 30 ❑ Specify Type 41 El Holding Tank <br /> 12 11 Seepage Trench 22 LJ 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) ELEVATION 5-7 ,,? 1 , , 3-3--3 100t(1-1 7eet 02,9LFeet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks <br /> Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> _ Tanks Tanks strutted <br /> �_eptic`rankak Holdinct Tank %QOQ <br /> um Tan i hon Chamberl bmX> 5 <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility f4 installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name Print): PI bar's ignatur :(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> )E (S v 7 �� lZ Y <br /> Plumber's Address(Stre City,State,Zip Code <br /> �c> � <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Ise ' Agent S' ture(No Stamps) <br /> Approved F-1OwnerGiven Initial (Surcharge Fee) j J <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />