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SANITARY PERMIT APPLICATION <br /> DILHR In accord with ILHR 83.05,Wis.Adm.Code couN <br /> rn <br /> STATEANITAFIPERMIT#�,((0913 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ /7(p05 <br /> 6'S X 11 inches In size. ack if revision to previous application <br /> -See reverse side for instr ictions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION .��// <br /> (0 9 /0A*SW ''/a,S Z T N, R 6 E (or W <br /> PROPERTY OWNER'S MAILING A DDRESS LOT III MUCK <br /> 3,110 ES Cr <br /> CITY,STATE ZIP CODE PHONE NUMBER S <br /> rima-Ax 0 0 1003285-goig63 <br /> 11. TYPE OF BUILDING: (C leek one) ❑State Owned in VILLAGE: ^� RT R DW <br /> ❑ Public 1 or, Fam. Dwelling-#of bedrooms 3PM <br /> A ( C <br /> III. BUILDING USE: (If builc Ing 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 ❑ 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. 'Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Permi was previously issued. Permit# — Date Issued <br /> V. TYPE OF SYSTEM: (Ch k only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 )EKseepage Bed 21 El 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 2.At SORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> rn RE IRED(sq.ft.) PROPOSED(sq.ft.) (Gals/dg/sq./sq.ft.) (Min./inch) o ELEVATION <br /> 5V Zo b ` J Feet 0Z • S Feet <br /> VII. TANK CAPACITY Site <br /> In allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New istin Gallons Tanks on cret glass App. <br /> ank Tanks structed <br /> Septic Tank or Holdin Tank — <br /> Lift PumpTank/SI hon Chamber <br /> VIII. RESPONSIBILITY STA rEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> TICZG lS X66 �{rS7 <br /> lumber's Address(Street,City,E ate,Zip Code: <br /> 2_Q`6w 35 0 l,Jii- 5`4993 <br /> IX COUNTY/DEPARTMEN USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a essue Isa n Agent SI ure(No Stamps) <br /> Surcharge <br /> Approved ❑ Owner Give Fee)Initial �4t M L/+,/ cd� <br /> Adverse Dot rmi I�O' <br /> tin �j CD dV' <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-&qN(formerly Pib$7)R.11/ II) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />