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SANITARY PERMIT APPLICATION <br /> COUNTY <br /> Law, <br /> 11116.1111 In accord with ILHR 83.05,Wis. Adm. Code ,,11 <br /> STATESANITARY PERMIT#�_�`� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑(_kko\0 6400\ <br /> 8%x 11 inches in size. <br /> 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 LETA <br /> ION <br /> D Mc 4,S ?js T� , N, R I (ora <br /> PROPERTY OWNER'S MAILING DDRESS BLOCK# <br /> 370 1 <br /> CITY,STATE ZIP CODE PHONE NUMBER <br /> G 5 0 3- 2887 ?11. TYPE OF BUILDING: (Check one) 1:3 NEAREST ROAD <br /> �-�t State Owned n F❑ Public V1 or2Fam.Dwellirl bedrooms L (S) <br /> III. BUILDING USE: (If building type is public,check all that apply) U�'tv3�'�Q` _�W <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.JR 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 /> 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 SYSTEM INFORMATION: <br /> 1.GALLONS PEF7 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERI.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REO IRED1 AREA <br /> ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) t^ AELEVATION <br /> �0 O 2GI 3Z (�— J -6 Feet qq•0 Feet <br /> VII. TANK CAPACITY Site <br /> In allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdinq Tank JTDOI 1200 <br /> Lift Pum Tank/Si hon 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:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> f aHx►2A o x`A!S yZG iS ) 966- 00 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> t7*7 60 #WX 3S LJ1E6Srf5X j Lit- SLf 8`4 3 <br /> IX. COUNTYIDEPARTMEN USE ONLY <br /> Disapproved Sanitary Permit Fee flncludes Groundwater Date Issued Issu' en Sig toe(No tamps) <br /> Approved ` Surcharge Fee) p <br /> ❑ Owner Given Initial _$�0 O"'b <br /> Adv rse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />