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SANITARY PERMIT APPLICATION COUNTY <br /> aOILHR In accord with ILHR 83.05,Wis.Adm.Code —�- <br /> - �:�J.F:;�lc i <br /> �M�• �_ STATE SANITARY P MIT# r- <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <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 /> L(. 3`a,5W'/4, S 20 T N, R 1 SE(or W) <br /> P OPERTY OWNER'S MAIL NG ADDRESS LOT# BLOCK N <br /> \AIAL <br /> CITY,STATE ZIP CODE PHONE NUMBER / <br /> 0 J�J �i CCN 1I.W t <br /> It. TYPE OF 13UILDI G: (Check one) Li CITU NEAREST ROAD <br /> ❑State Owned .} VILLAGE A 9 C SKI <br /> PQ <br /> [:] Public 1 or 2 Fam. Dwelling—#of bedroomsJ.. AR M C•/—C_ <br /> III. BUILDING USE: (If building type is public,check all that apply) l — <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) 1New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.El 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 ElHolding 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.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED q.ft.) PROPO ED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) // LE,ON <br /> Z IOi,� Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Zillions <br /> ota #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic 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): PI It 's Signature: S ps) MP/MPRSW No: Business Phon Number: <br /> c 5 S7 <br /> Plum r' ddress(S.triset,City,State,Z1C e): /. <br /> V <br /> IX. COUNTYIDE ARTM NT USE ONLY <br /> Disapproved Sanitary Permit Fee(Ittcludee ereundweter Date esus Issuing Apenl ne[u a(No s) <br /> Approved ❑ Owner Given Initial ., surcharge <br /> Fee) l O <br /> Adverse <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBO-6398(formerly Plb67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />