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(�U SANITARY PERMIT APPLICATION COUNTY <br /> UIL1-1R In accord with ILHR 83.05,Wis.Adm.Code <br /> STATENITARY'PERMIT#jqC, <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ❑ /�G t,1 ) <br /> 8%x11inches insize. ceckIfrevla 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 PRO RTY LOCATION <br /> NQJ %5E ''/a, S 2_ T31 , N, R ( E (or W <br /> PROPERTY(OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 2fog`t ) co - RO_Ki S9 <br /> CITY,STATE Wk <br /> ZIP CODE PHONE NUMBER !/��o <br /> II. TYPE OF BUILDING: (Check one) CITY '\ NEAREST ROAD <br /> ll��I ❑ State Owned VILLAGE: <br /> V SK �� <br /> ❑ Public 1al 1 or 2 Fam. Dwelling,#of bedrooms Z PARCEL TAX NNUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) pC�—3)Vc D <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) 1.9 New 2. ❑ 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�Seepage Bed 21 ❑ Mound 30 ❑ SpecityType 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.ASSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> L <br /> Soo I80 43o rbZ Q`�•(o Feet 9 60. 0 Feet <br /> VII. TANK CAPACITY Site <br /> 111ons Total #of Prefab. Fiber- Expp. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name ncret Con- Steel glass Plastic App <br /> structed <br /> Tanks Tanks <br /> Se tic Tank or Holdin Tank <br /> Lift 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 Signature:(No S ps) MP/MPRSW No.: Business Phone Number: <br /> l c N 31-rz <br /> Plumber's Address(Street,City,State,Zip ode: <br /> w 35" U4 3ST 1- S1 91)3 <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee undudar Grow water a ssu Issuin A nt Si ature( amps) <br /> Approved Owner Given Initial �p ri'1- <br /> A v rse De rminati n J <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-M8(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />