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�Di�HR SANITARY PERMIT APPLICATION CGUN <br /> In accord with ILHR 83.05,Wis.Adm.Code n <br /> dt- <br /> �•�� STATEITAR RMIT#9p`q�C� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 71 <br /> 8'%x11inches insize. ❑ Chrifrevisio previous application <br /> —See reverse Side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PR9ff RTY OWNER PROPERTY LOCATION <br /> '/4 '/4,S T-31 , N, R 14 E (Or W <br /> PROPERTY OWNER'S MAILING ADDRESS BLOCK# <br /> 21003 ODDS LN - <br /> CITY,STATE ZIP CODE I PHONE NUMBER SUBDIV <br /> gas, ' 337 11111 <br /> It. TYPE OF BUILDING: (Check one) 13 CITY NEAREST ROAD <br /> ��,77tt ❑ StateOWned VILLAGE <br /> ❑ Public Xh or 2 Fam.Dwelling-#of bedrooms_ L ( ) <br /> 111. BUILDING USE: (It building type is public,check all that apply) _ ,�a-- off-also <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. eplacement 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--P..,,ressurized Distribution Pressurized Distribution Experimental Other <br /> 11ASeepage Bed 21 ❑ Mound 30 ❑ Speciy 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 12.ABSOIRP.AREA 13.ABSORP.AREA 14. LOADINGRATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gels/day/sq.ft.) (Min./inch) ELEVATION <br /> `{Sb Z a -Z-(:) to Z 3 911 Feet Q-p Feet <br /> VII. TANK CAPACITY Site <br /> ingalTotal #oT Prefab. Fiber- Exper. <br /> INFORMATION New Istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank <br /> Lift Pump Tank/Siphon 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 Signature:(No S mps) MP/MPRSW No.: Business Phone Number: <br /> 3qz(. IS - q15 <br /> lumber's Address(Street,City,State,Zip Code <br /> 77,6uw .35 Wig- - 54902 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater [Date Issued Issuin A 1 1n mps) <br /> L.. Surcharge Feel <br /> Pproved ❑ Owner Given Initial 4L 13 �Q-2 <br /> v D ermin i n <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 6 Buildings Division,Owner,Plumber <br />