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SANITARY PERMIT APPLICATION COUNTY&! <br /> DILHR In accord with ILHR 83.05,Wis. Adm. Code <br /> moommo STATE SANITARY PERMIT#I ai(Linc <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ❑ (1� <br /> 8'%x 11 Inches In Size. Check if revis n to 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 /> PROPE9TY OWNER PROPERTY LOCATION <br /> IV, U1/4 W '/a,S ( 3 T 0 N, R /7E (o W <br /> PROPER OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> ZCITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> . Y, AT r W I S 9P 7 /S <br /> IL TYPE OF BUILDING: (Check one) State Owned ❑ CITY NEAREST ROAD <br /> VILLAGE tl <br /> ❑ De TOWN QF: <br /> Public �31 or 2 Fam. Dwelling–#of bedrooms 'PARCEL TAX NUMBER(S) <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 ❑ 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. V1 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 ❑ 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 PEREJ 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED AREA <br /> ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 3 D C9 / c 3 a-S ko Feet if Feet <br /> VII. TANK CAPACITY Site <br /> ingallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank I 1WU ( W C <br /> Litt 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: o Stamps) MP/MPRSW No.: Business Phone Number: <br /> o r-ic <br /> ° v o s, <br /> Plumber's ddre s(Street,City,State,Zip Code): t� <br /> 0 <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e sau Issuing gent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial ,qq��Surcharge Fee) <br /> Adverse vV -�3 0� <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&Buildings Division,Owner,Plumber <br />