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SANITARY PERMIT APPLICATION COUNTY <br /> �DILHR In accord with ILHR 83.05,Wis.Adm. Code <br /> ' STATE SyN�TARY P MIT#���(,�(� <br /> =MEMO e)U PN E71- <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than / jiJ <br /> 8%x 11 inches in size. ❑ Ch If revision <br /> 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. 's — C C <br /> PROPERTY.OWNER PRO ERTY LOCATION <br /> JaH STS ETS � 't/aNWY" S Z'i T ''� N, R E(o W <br /> P_Q <br /> OWNER'SOCILING A-DDjiESS LOT# BLOCK# <br /> CITY,STATE 'T 1L-ZIAIVIP DE PHONE NUMBER�_�� SUBDIVISION NAME OR CSM NUMBER <br /> Gi 2 IeA0 S�� <br /> It. TYPE OF BUILDING: Check one CITY : NEAREST ROAD <br /> ( ) State Owned VILLAGE 5 obm <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms ER _ <br /> III. BUILDING USE: (If building type is public,check all that apply) _(�r'�— /"� �' Ro � <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 X 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 ❑ Seepage Bed 271 Mound 30 El Specify Type 41 ❑ Holding Tank <br /> 12 El 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 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 3D Q REQUIRED(sq.ft.) PROPOSED((sq.tt.) (Ga /day/sq.ft.) (Min./inch) i/ ECL��QV/� ON <br /> ZSa L'. Z 7 Feat H o Feet <br /> I <br /> APACTY <br /> VII. TANK CSite <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New istin Gallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holdina Tankr-SE <br /> Lift Pum Tank/Siphon Chamber CflM <br /> VIII. RESPONSIBILITY STATEMENT <br /> [,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plum rs Signature:(No S Strips) MP/MPRSW No.: Business Phone Number: <br /> RICAWD lkifX10 E14" Al <br /> 15 sk-Y/57 <br /> Plumber's Address(street,City,State, <br /> wEffroz 11 -51n ) <br /> OUN11((77_TYco <br /> V w/DEPART ENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued, Issuing gent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial _ Surcharge Feel <br /> Adverse i <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly P115-07)R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />