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SANITARY PERMIT APPLICATION <br /> C4-CIn accord with ILHR 83.05,Wis.Adm.Code cou4,rge7"/ <br /> "I <br /> STATES ITAR/Y� IT#a� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ��"I <br /> 8%x 11 inches in size. ❑ Ghec if revision to revious 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 /> PR ERTYOWNER PROPERTY LOCATION <br /> /1'1 43 416 '/411l(.t1'/4, S T3(� , I1, R <br /> PROPERTY OWNER'S MAILING ADDRESS LOT If I BLOCK# <br /> s'� urK ✓t? ). <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> s YYi n. Ss r �r a <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned O VILLAGE TRW : 1 . f_'_//e wt k/p R,4- <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms PAH1jFL I AX NUMBER(, J <br /> 111. BUILDING USE: (If building type is public,check all that apply) ! — r�-,O�j'- 0 O <br /> �— M <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. X 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 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 PE7 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERI.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) p ELEVATION <br /> �d /p,1 Feet Feet <br /> CAPACITY <br /> VII. TANK 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 structed <br /> e ticdorHoldin Tank OO / ICSFtr <br /> Lift Pum Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility f installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Pr nt): Plu ber's Signatur : Stamps) MP/MPRSW No.: Business Phone Number: <br /> PV' <br /> Plumber's Address(Street,City,State,Zip Code): <br /> C d ✓ 9'9 3 <br /> 11. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(in cWas <br /> Groundwater Date IssuedIssuing gent Signature(No Stamps) <br /> �•qu.� Surcharge Fee) <br /> pproved ❑ Owner Given Initial `--f* 1� /40 <br /> Adverse Determination / L��/ I 01 CGGt) <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(RoM3) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />