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rZygnE!ggeSANITARY PERMIT APPLICATION <br /> In accord with ILHR 83mammon .05,Wis.Adm.Code COUNTY <br /> STATE SANITARYERMIT# V3251ti$ <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than (tLf�1� <br /> 8'%is 11 inches in size. ❑ Check if revision 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 rRELRA.1,ION <br /> R KR E E ,$ 2 T yo, N, R 6 E (or)PROPERTY OWNER'S MAILING ADDRESS BLOCK#CITY,STATE ZIP CODE PHONE NUMBER E OR CSM NUMB R <br /> ` 01,54016 'll S ` cv11 �9K2 /l <br /> If. TYPE OF BUILDING: (Check one) ❑State Owned LAGE U CITYNEAREST ROAD <br /> ❑ Public X 1 or 2 Fam. Dwelling-#of bedrooms.3 A M ( ) CCC . <br /> C G <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) 1LNew 2. ❑ Replacement 3. ❑ Replacement of 4. [1 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 ElIn-Ground42 ❑ 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 3.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) QELEVATION <br /> X50 61S aaV l o a to r13,1 Feet 1 1.0 Feet <br /> VII. TANK CAPACITY Site <br /> ingallons Total #Of Prefab. Fiber- Exper. <br /> INFORMATION New is Gallons Tanks Manufacturer's Name oncret Con-tteSteel glass Plastic App <br /> Tanks Tanks strud <br /> Septic Tank or Holdin Tank o <br /> Litt Pum Tank/Siphon ChamberF1 I <br /> Vlll. 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): Plumber's Sig ature:(No mps) MP/MPRSW No.: Business Phone Number: <br /> FOPEKICK o K I O0 o3 ( 71-5 )2 - T-51rQ . <br /> Plumber's Address(Street,City,State,Zip Co e): <br /> 2'7 I6o uJ 35 WF_951-eR Lot 54913 <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> �f ❑ Disapproved Sanitary Permit Fee(Incluees Groundwater Date ue Issuing Agent Sign ure o mpg) <br /> Approved ❑ Owner Given Initial GL+ bs°mnarge Fee) C <br /> Adverse Determination \D � `/ (b <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6M(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />