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SANITARY PERMIT APPLICATION <br /> DILHR In accord with ILHR 83.05,Wis.Adm.Code couNTYOU r <br /> STATE yANITAR ERMIT#1f1S]�c <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8'%x 11 inches in size. ❑ c k Ir revlsi,0 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 OW RPROPERTY OCATION / <br /> S T (/, N, R 6 E (or) <br /> PROPERTYO ER'S MAILING ADDRESS LOT# BLOCK <br /> t �. <br /> CITY, TATS , '\�• ZIPICODE PHON�NUMBERtnl �� b ,/ �e�L� 1 <br /> II. TYPE O BUILDING: (Check one) 1b CITY L K NEAREST ROAD J <br /> ❑ State Owned VILLAGE Orr k )Jt7 <br /> ❑ Public 1 or 2 Fam. Dwelling—#of bedroom A L MBE <br /> III. BUILDING USE: (If building type is public,check all that apply) �0 309, _ODD <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 V 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 Permit was previously issued. Permit# — Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11XSeepage Bed 21 ❑ Mound 30 EJ 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.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REOUIRED(sq.ft.) PROP SED(sq.ft.) (Gals/day/sq.ft.) ( ./inch) ELEVATION <br /> 5O <br /> (b1 (U1 {V 1 Feet 520Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass <br /> Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdina Tank C BD <br /> Lift Pum Tank/Si hon Chamber <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): Plurpber's Signature: No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> v-76) �,i 3S WE851-F-e . <br /> IX. OUNTYIDEPARTM NT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(includas Groundwater ae ssue Issuing Agent Si atur oSt m <br /> y} Surcharge Fee) rt <br /> Approved ❑ OwnerGivenDetermination <br /> etermial y.) //1� Irl <br /> 00, <br /> Adverse De rmin tion Y lJ Vl/ <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD41398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />