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IZIDILHR SANITARY PERMIT APPLICATION COUNTY <br /> n <br /> In accord with ILHR 83.05,Wis.Adm.Code (_ <br /> e � <br /> STATL NITAR ERMIT# 13�-Attach complete plans(to the county copy only)for the system,on paper not less than Ll-S8'h x 11 inches in size. It if revisi to prevloua 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 NER PROPERTY LOCATION. <br /> VS 0�. '/s Ya,S T N, R <br /> PROPER Y OWNER'S MA NG ADDRESS l LOT# BLOCK# <br /> � <br /> 7 7 S• x v <br /> TY,STAZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER f1S <br /> ke)1144-4-T 16WrS She O 7(S y63.53G ��v 5ci DF WooD u3Kc <br /> CITY NEAREST ROAD <br /> if. TYPE OF B DING: (Check one) ❑State Owned VILLAGE: l �� <br /> LOU W:11 <br /> ❑ Public N 1 or 2 Fam.Dwelling-4 of bedrooms PARCEL ) <br /> III. BUILDING USE: (If building type is public,check all that apply) 90'7!S-0/-5000 <br /> 1 [1 Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7ElMerchandise: Sales/Repairs 11 E] 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 N applicable) <br /> A) 1. ❑ New 2. ® Replacement 3. El 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# — Dale Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 ❑ 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 3.ABSORP.AREA 14. LOADING RATE 5. PERC,RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.tt.) PROPOSED(sq.ft.) (Gals/day/sq.K.) (Min./inch) ELEVATION <br /> 49 eV^ Feet Feet <br /> VII. TANK CAPACITY Site <br /> in alions Total #ofPrefab. Fiber- Exper. <br /> INFORMATION New istiGallons Tanks Manufacturer's Name ConcreteCan- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or<ldln Ta ZLos <br /> Lift Pump Tank/S hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for Irptallation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Prin Plum is Sig ure:( S ps) MP/MPRSW No.: Business Phone Number: <br /> (! -14e l* P Rf �7j_ <br /> Plumber's Address(Street City,State,Zip Code): <br /> T 40 -C 6pCe W(--S � <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e asup Issui AjWii >gnalure(No Stamps) <br /> �Y/��• cV SurMarpa Fee) <br /> Approved ❑ Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-M8(formerly Plb-87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 6 Buildings Division,Owner.Plumber <br />