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SANITARY PERMIT APPLICATION <br /> COUNTY <br /> 7DILHR In accord with ILHR 83.05,Wis.Adm.Codes^IES <br /> _ STATE�ANITARY RMIT# 13r7� <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than / �j��a�r� I <br /> 8'%x 11 inches in size. ❑ Check if revisi to 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 /> PROPERTY OWNER PROPERTY LOCATION <br /> Q <br /> Z, 1/4 1, %4, S T N, R / (o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# - <br /> R / -?nt, 33 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISI NAME OR CSM NUMBER <br /> l/rccc- Mf! -z) o <br /> II. TYPE OF BUILDING: (Check one 11 CITY NEAREST ROAD <br /> El State Owned ❑ VILLAGE <br /> ❑ Public �yor 2 Fern. Dwelling–#of bedrooms A M UMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) <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. XNew 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 /> 11Seepage Bed 21 ElMound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 nseepage 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 15. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> ?? n REQUIRED(sq.ft.) PROPOSED sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 41 / q X0 I Feet Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank 7 WZW5AW V/�-r <br /> Lift Pum Tank/Siphon 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): Plum i re: oS mpa P/MPRSWNo.: Business Phone Number: <br /> fo7a— 2 Jzs� <br /> Plumber's Address(Street,City,State,Zip Code): <br /> I'T 3 7D /�.�� l ijB�U <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> Disapproved San'tary Permit Fee(Includes Groundwater Date IssuedIssuing ent Signature(No Stamps) <br /> /V5_,MS <br /> Surcharge I") <br /> pproved ❑ OwnereDet Initial <br /> ermination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb$7)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />