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SANITARY PERMIT APPLICATION <br /> DILHR In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STATE SANITARY gERMIT#'nrC n <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ❑ –711 ` LJ <br /> 8%x 11 inches in size. ch k If revikl)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 PROPERTY LOCATION <br /> T Y0, N, R ( W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> S Tti ree (� d q � <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CS NUMBER ' �4 � 4� Nf,6 A—d f <br /> 83o fS S a <br /> 11. TYPE O BUILDING: Check one) CITY NEAR ST ROAD <br /> ( ❑State Owned VILLAGE TryJQ( 0scrn <br /> ❑ Public ®1 or 2 Fam. Dwelling–#of bedrooms PARCEL TAX NUMBERS) I r1 1� <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo �J <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 Other <br /> 11 X Seepage Bed 21 ❑ Mound 30 ❑ 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 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> 3c)0 <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) LEVATION <br /> N ?o 4$o I r 60 3,3_3 Feet 7. 5 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Pretab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> tic T or Holding Tank l C <br /> LIN Pump Tank/Siphon Chamber El <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility fat installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Pluature (N tamps) MP/MPRSW No.: Business Phone Number: <br /> >°(S bar's gn <br /> r 5-18 7 <br /> Plumber's Address(Street, ity,State,Zip Code): A <br /> t t(J C <br /> IX. OUNTY/DEPARTM NT USE ONLY <br /> Disapproved San. ryPermit Fee(Includes Groundwater a e asu Issuing Ag SI r mps) <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial (3�,/ <br /> Adverse Determination vV / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />