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IR SANITARY PERMIT APPLICATION COUNTY--r--) r <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITAR PERMIT#Jq�j <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ❑ i7lo <br /> 8%x 11 inches in size. eckurevi3 n 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 /> '/a '/.,ST N, R 1J E ( W <br /> PRO TY OWNEWSMAILINGDD ESS LOTS BI OSE60 <br /> So f 5� IDGE 1 L <br /> Oily,STATE IZIPCODE PHONE <br /> UMBER SUBDIVISION NAME ' CSM NUMBER• 4� <br /> 11Lj CITY <br /> . TYPE OF BUILDING: (Check one) L1 state Owned VILLAGE: ✓ �{ NEAREST ROAD <br /> El Public �1or2Fam. Dwellingofbedrooms ILI=xNUM L+ <br /> Ill. 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. D4 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 /> 11Seepage Bed 21 L1Mound 30 ❑ Specity Type 41 ❑ Holding Tank <br /> 12 N 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 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> RE U RED(sq.ft.) PROP SED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> q0 Il>. 'jy7 Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdinct Tank <br /> Lift Pum Tank/Si hon 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 /> D l ` f s <br /> lumber's Address(Street,City,State,Zip Code): 41 <br /> a LJW4 35 w1w tEQ W ( _S,1913 <br /> IX. OUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(includes Groundwater ae ssue Issuin nt S' r mps) <br /> AApproved ❑ Owner Given Initial 136. <br /> '�/ cc Surcharge Fee) <br /> AdverseDetermination <br /> /`�L.J lilt <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/86) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />