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WOMMMMMMMM" SANITARY PERMIT APPLICATION <br /> i 1-1 QILHR In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STATE�AAAAN,IT1ARY MIT#a3G-' <br /> � <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than / d' � <br /> 8'%x11inches insize. ❑ Ch kifrevi n previous application <br /> -See reverse Side for Instructions for completing this application. STATE PLAN I.D.NOMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION i <br /> 4 u G ^o.j -ir U '/a �'[''/a,S at T N, R /� E (O W <br /> PROPERTY OWNER'S MAILING ADDRESS / LOT# BLOCK# <br /> a R �sr �tood Tr— dV <br /> CITY,STATE <br /> {� ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSS/y1 NUMBER <br /> N4�4i '19 wl . JO V• � fNEAARESTROAO <br /> �� �• l�-QV l... L-Fi�� <br /> If. TYPE OF BUILDING: (Check one CITY , <br /> ❑ State Owned VILLAGE ovg rac <br /> ❑ Public 1�1 or 2 Fam. Dwelling-#of bedrooms PA L A NUMBER(S) <br /> ER( ) <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. L,�g 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 /> V YSTEM INFORMATION: ,r L[X <br /> ALLONS PER DA;M 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 4 r50• EQUUIIRED(sq.fL) PROOPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) GL ELEVATION <br /> ( S U µJ. a � (D U . S3 Feet '7 2"� Feet <br /> VII. ANK CAPACITY Site <br /> !,:- in gallons Total #of Prefab. Fiber- Exper. <br /> New istin Gallons Tanks Manufacturer's Name ConcreteCon- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdin Tank /J�� I C:- <br /> LittPum Tank/Siphon Chamber S(2 I <br /> VIII. RESPONSIBILITY STATEMENT <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:(No Stamps) MP/MgPRSW No.: Business Phones Number:/ +'7 <br /> 11 0 �-e r•t C- o /l �e S O'Zx1.�eti/� o f c S I L D /G-✓ <br /> Plumber's Ad reqs(Street,City,State,Zip Code): <br /> I . COUNTY/DEPARTMENT USE ONLY <br /> Ej Disapproved Se i ry Permit Fee(Includes Groundwater e e ssue Issuing gent Signature(No Stamps) <br /> Approved Owner Given Initial ��Surc arge Fee) <br /> ❑ I(�C'/ I I_9-Q � <br /> Adverse D termin tin f�J LTJ <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 />