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SANITARY PERMIT APPLICATION COUNTY <br /> 70ILHR In accord with ILHR 83.05,Wis.Adm.Code MMEMOM (n ._[L_ <br /> it {; n <br /> 7 <br /> STATE SANITARY MIT#/3�0g <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than K��l�� <br /> 8%x 11 inches in size. 1:15l/ <br /> Che�I�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 PROPERTYLOCATION <br /> r w 66_r114_'e 11 '/4, S S T 3�N, R /,�'E (or W <br /> WTPR PERTY OWNER'S MAILING ADDR SS LOT# <br /> a rive , r70 cin ✓. �{�,i3 <br /> Cc$Tq'j€� W;, ZIP COD `� PHONE NUMBER / SUBDIVISION NAME OR CSM Nkr U BER <br /> IL TYILPE t!O`FF BUILDING: (Checkone) / e l� Li CITY NEAREST ROAD S j <br /> ��--qq,, State Owned VILLAGE ��F. <br /> r>,e <br /> ❑ Public L�1 or 2 Fam. Dwelling,#of bedrooms a14 u ( ) "C //���9 <br /> III. BUILDING USE: (If building type is public,check all that apply) l�l —p�SQ� 0—50o <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. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank OnlyExisting 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 ElMound 30 ElSpecify 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. T FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.jftt.) (Min/inch) � ELEVATION <br /> a % Z) 3 1 . • a Feet S. �2—Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New istin Gallons Tanks c ncret <br /> Tanks Tanks strutted glass App. <br /> Septic Tank or Holding 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 /> PI mb}is Name(Print): Plumber's Signature:(No Stamps) MP/MPRSWNo.: Business Phone Number: <br /> o drrl c o s o 0 7 pr ! <br /> Plumber's ddress(Street,Clt/,State,Zip Code): <br /> W W�1— SC/ <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes eroundweter ate IssuedIssuing A ent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial — �surcherge Feel / <br /> Adverse Determination * <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: CCCCJJJ <br /> SBD-6399(formerly Plb-67)(R.11/98) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />