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l✓'rI w r/ <br /> SANITARY PERMIT APPLICATION GDt,Nr <br /> DJLHR In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITAR�Y PERMIT$InS�n <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ 17�, '\ 11 II <br /> 8r%x 11 Inches In size. eck if rev`lifon 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 PROPERTY LOCATION r� <br /> GROPP©L I '/4 '/a, S 2, T , N, R 5 E(or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT N BLOCK II <br /> Cl ,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER, <br /> `y, PAat- KO . i -e csm� .n Lo <br /> 0 TY <br /> II. TYPE OF BUILDING: (Check one) ❑State Owned VILL AGE_"W( , ] REST ROA ' <br /> ❑ Public1 or 2 Fam. Dwelling #of bedrooms 3 Mr 1 R( ) 1v <br /> 111. BUILDING USE: (If building type is public,check all that apply) 'a— 4aaS(D(o hoc) <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. XReplacement 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 ❑ Specify Type 41 El Tank <br /> . <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 91 2.ABSORP.AREA 3.ABSORP.AREA 4. 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 /> 15) 120 17zn Z •3 Feet .Q Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Manufacturer's Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank <br /> Lia 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 /> Plu bar's Name(Print): Plumber's Signature:(No tamps) MP/MPRSW No.: Business Phone Number: <br /> L <br /> Plumber's Address(Street,City State,Zip de). W � I <br /> 27 <br /> t/D v <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> ❑ anitary Permit Fee Includes Groundwater a e sou Issuing Agent Si natur (No S <br /> ) <br /> Disapproved FSSurcharge Fee) <br /> Approved ❑ Owner Given Initial <br /> Adverse Determination J <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 8 Buildings Division,Owner,Plumber <br />