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SANITARY PERMIT APPLICATION COUNTY <br /> va�rnn In accord with ILHR 83.05,Wis.Adm.Code S4e N1 <br /> STATE ANITAR ERMIT#aa <br /> —Attach complete plans(to t e county copy only)for the system,on paper not less than 1 'yI/���� <br /> 81/2x 11 inches in size. ❑ L Jisid to previous application <br /> -See reverse side for instru tions for completing this application. STATE PLAN I.D.f4UMBER <br /> I. APPLICANT INFORMATI N-PLEASE PRINT ALL INFORMATION. <br /> PROPE TY OWNER LERA,LOCATION <br /> q f44 F '/a, S _7T �/, N, R ♦;{�l <br /> PROPERTY OWNER'S MAILING p DRESS BLOCK# <br /> 37 9.S� .P`! LK c�IPCODE PHONE NUMBER ME OR CSM NUMBER <br /> bg3iII. TYPE OF BUILDING: (Ch)ckone) 13 NECA sT RpgpdF- <br /> Hyl ❑StateOwned /CPublic M1 ort am. Dwelling-#of bedroomsMBER(,, ) <br /> III. BUILDING USE: (If buildi ig type is public,check all that apply) _ / f I�- <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: (Cheft 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 Permit was previously issued. Permit# Date Issued <br /> V. TYPE OF SYSTEM: (Ch ck only one) <br /> Non-Pressurized Distribu ion Pressurized Distribution Experimental Other <br /> 11Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 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 SYSTEMINFORMATION: <br /> 1.GALLONS PER DAY 2.A SORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REO JI (sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 31�Q ^ ^�— r Feet 8 Feet <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 Plastic App <br /> rank's Tanks ' ff strutted <br /> e n or Holdin Tank Ove- <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STA EMENT <br /> t,the undersigned,assume rf sponsibility for in tallation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print: Plum �s Sigy�ture:(No t s) MP/MPRSW No.: Business Phone Number: <br /> �lS �f '7l S B �uk� <br /> Plumber's Address(Street,lCity,S late,Zip C de): <br /> � / s C ' k �r3 <br /> IX. COUNTY/DEPARTM USE ONLY <br /> Disapproved SaniL ryPermit Fee(Includes Groundwater a e ssue ]as Agent Si lure(No Stamps) <br /> J} Surcharge Fee) <br /> Approved ❑ Owner Giver Initial ��1(Fl IL�"l,jr),2,Adverse Det rmination —�lJ Lq <br /> X. C NDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety8 Buildings Division,Owner,Plumber <br />