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SANITARY PERMIT APPLICATION <br /> TDILHR In accord with ILHR 83.05,Wis.Adm. Code COUNTY <br /> ��•��� STATE SANITARY PERMIT#l al o3>-� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ ' <br /> 634 x 11 inches In size. Chet If revision t revious 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 /> PROPARTY OWNER PROPERTY LOCATION p <br /> 1/4/1(f ''/a,S T, d , N, R / E (or <br /> PRO RTY OWNER'S MAILING ADDRESS �,/ LOT# BLOCK# <br /> r e0/ C/. <br /> CITY STATE ZIP C DE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> �5iier, lac/I F7A /S <br /> It. TYPE OF BUILDIN : (Check one) CITY NEA EST ROAD <br /> State Owned VILLAGE : ��,� <br /> ❑ Public 1or2Fam. Dwelling-#ofbedrooms AANNtJMBER(r)fIp <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. ❑ Replacement 3. ❑ Replacement of 4. ElReconnection 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 �HoldingTank <br /> 12 ❑ Seepage Trench 22 ElIn-Ground42 Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAI 2.ABSORP,AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istln Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks Site <br /> Septic Tank or Hoidin 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: Stamps) MP/MPRSW No.: Business Phone Number: <br /> It1we ' m �� rl I <br /> Plumber's Address(Street,City,State,Zip Code <br /> IX.A COUNTY/DEPARTMENT USE ONLY <br /> Disapproved nary Permit Fee(Includes Groundwater e e esus Issuin ent Signature o Stamps) <br /> Approved ❑ Owner Given Initial <br /> Surcharge Fee) <br /> Advera <br /> Determination <br /> 105 �2c <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 />