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FZEDILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> • � STATE S,�NITARY PERMIT#(-7S <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than / /�� <br /> 8%x 11 inches in size. ❑ Chec if ravisl 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 OWNER PROPERTY LOCATION <br /> UJ{9 , L< C % At LC '/4, S TN, R J E(o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> a0? /3 vis sr r r�h�S �ti� , + <br /> CITY,STATE ZIPCODE PHONE NUMBER SUB 1 ISION NAME OR CSM NUMBER <br /> El <br /> It. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ❑State OWnedVILLAGE lheL 2.1> <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedroom AX ER( <br /> III. BUILDING USE: (If building type is public,check all that apply) Cr% yj� <br /> 1 ❑ ApVCondo <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: (Checkonlyone in line A. Check line B if applicable) <br /> A) 1. ❑ New 2. I dJ 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 l weepage 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 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) -7/ (ELEVATION <br /> 1500 gle0 (4 p G r 63 � / -,-,' Feet /Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank L 7Y Lt 1 1 1 T• W c <br /> Litt Pump Tank/Siphon Chamber <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 tura:(No Stam MP/MPRSW No.: Business Phone Number: <br /> Rc&oti/) & -!�/loTfl <br /> Plumber's Address(Street,City,State,Zip Code): <br /> ler 3 o <br /> X. OUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater ae Is ad Issuing Agent ignatur (No Sta ps) <br /> Surcharge Fee) J / / <br /> Approved ❑ owner Given Initial l/Jtyvl ///- <br /> Advo Determination <br /> X. 6ONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />