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SANITARY PERMIT APPLICATION <br /> 71 1L1-Ifl In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> Ems• �• STATE ANITARY-PERMIT#,2(D) <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ( 60 <br /> 17aa I) V OO�Nv <br /> 8'%x 11 inches in size. ❑ 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 OWNEROPERTY LOCATION <br /> P <br /> l ,L-11, '/a, S35- T � , N, R IG E(or W <br /> PROPERTY OWNER' M NG ADDRESS LOT# BLOCK III <br /> 23 Q• IS M4040 I <br /> CITY,STATE JZIIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> AUL O V, <br /> I. TYPE OF BUILDING: (Check one CITY : NEAREST ROAD <br /> I <br /> ❑State Owned ❑ VILLAGE: I 2rTOWN QF:. �� <br /> ❑ Public 1 or 2 Fam. Dwellings of bedrooms Z A N <br /> III. BUILDING USE: (If building type is public,check all that apply) <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.,M 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 El HoldingTank <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 PERDAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REO IRED AREA <br /> ft.) PROP SED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 4siD 0 'OZ _�3 114 .9Feet i R D Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Expp. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank C <br /> Lift Pum Tank/Si hon Chamber On 4r " Bloom L <br /> VIII. RESPONSIBILITY STATEMENT -rm L <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 S ps) MP/MPRSWNo.: Business Phone Number: <br /> !c p oJ'Ki s - 3` f5 66-`IIS <br /> Plumber's Address(Street,Ci ,State,Zip Code): r <br /> \1 wc,65mz W ii <br /> IX. COUNTY/DEPARTMENIJUSE ONLY 111 <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater 9 e ssu Issuin nt 1 atur ( Stamps) <br /> Approved ❑ Owner Given Initial �}-I2�=e�aurcharge Fee) <br /> Adverse Determination (YT <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />