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SANITARY PERMIT APPLICATION COUN <br /> DILHR In accord with ILHR 83.05,Wis.Adm.Code (� <br /> STATESANITARY INERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than� ( <br /> 814 x 11 inches in size. ❑ k Ii revision 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 PROP RTY LOCATION ✓/ <br /> S T C, N, R l E(o W <br /> PROP TY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> CAMPBELLLin <br /> CI ,S ATE I ZIP CODE PHONE NUMBER 7 SUB <br /> �2 15 6 1 <br /> Il. TYPE OF B ILDING: (Check one ❑ $t8t@ OWr1ed CITY VILLAGE:: NEAREST ROAD <br /> _ <br /> ❑ Public 1 or 2 Fam.Dwelling,#of bedrooms3 L AX ( ) <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 ❑ RestaurantlBar/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: (Chtr my one in line A. Check line B if applicable) <br /> A)- yes <br /> ,C�1 Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> 77T 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 /> No -Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 El 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 PEF7 2.ABSORP.AREA 13.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> [7� 0 REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gall /day/sq.ft.) (Min./inch) ELEVATION <br /> (T ZO . l03 (�/'0 Feet o- Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdinct Tank ODD <br /> Lift Pum Tank/Si hon Chamber <br /> Vlll. 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 Signe ur .(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> it 0 3 26 It IS 9w Is-7 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 'Z. (ow 35 r�€B ST�12 w 1 �`lg`t3 <br /> X. C UNTY/DEPARTMENT USE ONLY <br /> L] Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Issui Agent Signature(No Stamps) <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial ' <br /> A v rse Determination u✓.� 1 <br /> k. C NDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly PlbB7)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />