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01112 SANITARY PERMIT APPLICATION <br /> DELI-IR In accord with ILHR 83.05,Wis.Adm.Code COUNTv <br /> — r uu--�� <br /> �• � STATE SANITARY RRMIT#�OI�i <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than C 73 -z1 <br /> 8'%x 11 inches In size. ❑ check If 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 PROPERTY LOCATION <br /> F ( E '/4 SF- '/a,S a. T N, R (or W <br /> PROPERTY OWNER'S MAILING AD RESS LOT# BLOCK# <br /> a S r-evF%ego no 111 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> r ` a! <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> �y State Owned VI GE �Lr•S <br /> ❑ Public LJ 1 or 2 Fam. Dwelling—#of bedrooms-3A L TAX <br /> Ill. BUILDING USE: (If building type is public,check all that apply) a NUMBERS) <br /> - -Zc <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 onl a in line A. Check line B if applicable) <br /> A) 1. ❑ New 2. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only, / Existing System Existing System <br /> B) Sanitary Permit was previously issued. Permit# �3 7t:b(o Date Issued `13—9Q <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non,-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 u 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 PER DAY 12.ABSORP.AREA 13,ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) I PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 7�d C� Fly Feet Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank 6001 1 <br /> Litt 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:( Stam hffNPRSW No.: Business Phone Number: <br /> 336 42/ <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date issued Issuin pent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial Surcharge Fee) ' <br /> Adverse Determination �3—b'(Do <br /> X. C NDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety8 Buildings Division,Owner,Plumber <br />