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assassassal <br /> DILF*IR SANITARY PERMIT APPLICATION COUNTY <br /> _ In accord with ILHR 83.05,Wis.Adm.CodeR�ET <br /> .e.,., s•�� STATES NITARYY''��RMIT#f'1 f5�s� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than SA I��/, ) uS <br /> 8'%x11inches insize. ❑ ch kgreviab topreviousapplication <br /> -See reverse side for instructions for completing this application. sTATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> P RTY OWNER PROPERTY LOCATION <br /> �1 LkP/a SIU I'/a, S if T q0, N, R &E(o6W2 <br /> PROPERTY NER'S MAILING ADDRESS LOT# BLOCK# �� <br /> T ,� �,,, e4- P � 1 <br /> CCIITY,SLAjE \ ZIP CO Q PHONE NUMBER SUBDIVISION NAM OR CSM NUMBER ,n^ i I �. L, j <br /> It. TYPE OF UILDING: (Check one) _17-CITY V/ NEAREST(R�O(A1D w J� <br /> ❑ State Owned q 40W VILLAGE:�C d�t1 <br /> ❑ Public M 1 or 2 Fam. Dwelling-#of bedrooms PARCELTAX Nu ER( <br /> III. BUILDING USE: (If building type is public,check all that apply) 1-a— 4301- 0'o--c <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. "Replacement 3. L1Replacement of 4. ❑ Reconnection of 5.F-1Repairof 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 PE2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) / S ELEVATION <br /> R DAY <br /> (D S I (p / Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic App. <br /> INFORMATION New istin Gallons Tanks oncret structed glass App. <br /> Tanks Tanks <br /> Septic Tank or HoldingTank O <br /> Lift Pum Tank/Si hon Chamber rtgo F] I El <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): P er's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> OPo d e4-1C d c fa-0/4- 7 <br /> Plumber' Addre}ss(Street,Cityc State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e slue Is in gent Sig a(No Stamps) <br /> Surcharge Fee) <br /> A roved ❑ owner Given Initial r!��C�� �(5r) F- <br /> PP Adverse Determination I W` "" <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb87)(R.11/98) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />