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SANITARY PERMIT APPLICATION <br /> 17—01LHR In accord with ILHR 83.05,Wis.Adm.Code co <br /> �• � STATE �a�a�� <br /> -Attach SANITARY PERMIT# <br /> complete plans(to the county copy only)for the system,on paper not less than ❑ ecA�� <br /> 8%x 11 inches in size. chk ev slon o previous application <br /> -See reverse side for instructions for completing this application. s TE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PRO TY WNER PROPERTY LOCATION <br /> , N, R E (or <br /> E T <br /> PRO OWNER'S M ING ADDRESS LO # BLOCK# <br /> CITY,PTATE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 11. TYPE OF BUILDING: Check one) CIN : NE REST ROAD <br /> ( State Owned VILLAGE <br /> Public ❑1 or 2 Fam. Dwelling-#of bedrooms— R VI* <br /> Ax u <br /> 111. BUILDING USE: (If building type is public,check all that apply) O J54 _�00 <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. ❑ 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 Otheee,,,r{{{ <br /> 11 El Seepage Bed 21 El Mound 30 ❑ Specify Type 41 ySJ Holding Tank <br /> 12 ❑ Seepage Trench 22 ElIn-Ground4 Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PERDAY 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 /> Feet Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks 1 Tanks structed <br /> Se tic Tank or Holdin Tank <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. 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 Signature:IN temps) sP <br /> MP/MPRSWNo.: Business Phone Number: <br /> Plumber' Addr as(Street,City,State,Zi Co e): <br /> �e ler lam/ <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit I"(Inciudee Groundwater aessue I ui Agent Si ure(No Stamps) <br /> Approved ❑ Owner Given Initial O„l� Surcnarge Fee) <br /> Adverse D rmin tin 1 S <br /> k. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />