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SANITARY PERMIT APPLICATION <br /> ..■:":.R couNTv C <br /> tiffs-irl In accord with ILHR 83.05,Wis.Adm. Code <br /> STA ESANIT RY ER`MUIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8'%x 11 Inches In size. heck if revision to previous application w <br /> —See reverse side for Instructions for completing this application. STAI E PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER LPROPERTYATION0 F � ''/4, S T D , N, 4 E (Or WPROPERTY OWNER'S MAILING ADDRESS �� , IBLOC # <br /> 2 Co . n `-�CITY,STATE ZIPCODE PHONE NUMBER AME OR CSM NUMBER <br /> WlII. TYPE OF UILDING: (Check one NEAR STAD <br /> State Owned CC Public or 2 Fam. Dwelling-#of bedrooms LsM�BfE(R ) <br /> 111. BUILDING USE: (If building type is public,check all that apply) CR- -I 1(}Y (D_�, <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 ❑ Res urant/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. XReplacement 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 ❑ SpecityType 41 ❑ Holding Tank <br /> 12 n 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 7 2.ABSORP.AREA 3.ABSORP.AREA 4. 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 <br /> �OdZ • Z- Feet Feet <br /> CAPACITY <br /> VII. TANK 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 /> Tanks Tanks strutted <br /> Se tic Tank or HoldingTank <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 pi ans. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> !S <br /> Plumber's Address(Street,City,State,Zip Code): <br /> L (- <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved SanitaryP rmil Fee(Includes Groundwater [Date IssuedIssuing g nt Sign r (N tamps) <br /> Approved ,Surcharge Fee) `� <br /> ❑ Owner Given Initial o <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Ow r,Plumber <br />