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0-0 <br /> SANITARY PERMIT APPLICATION <br /> V��riACo NTY 1 ) <br /> In accord with ILHR 83.05,Wis.Adm.Code }I.IL <br /> STT SANIT�RY PE # <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than4 <br /> 8'%x 11 inches in size. <br /> heck if ision to previous application <br /> —See reverse side for instructions for completing this application. ST(JE PLAN I.D.NUMB <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. '11V <br /> PROPERTY OWNER PROPERTY LOCATION G 6u✓ <br /> j on' A,) e lsc .✓ '% % S / T VO, N, R /6 E (or <br /> � <br /> PROPER OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> / Co, c✓ F <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> C,r,4'A r614r &J- -1—Yeve — <br /> If. TYPE OF BUILDING: (Check one CIN / NEA EST ROAD <br /> ❑ State Owned // O VILLAGE �,4(/�4 i✓yr � n C <br /> ❑ Public �1 or 2 Fam. Dwelling—#of bedrooms L PARCEL TTAX-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 ❑ Re taurant/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. [KReplacement 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 Z 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 PER 7 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7, FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 5_C�2 — Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> S or HoldingTank L`�" - <br /> Lift Pum Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached r lans. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MWMPRSW No.: Business Phone Number: <br /> Pluu bar's Address(Street,City,State,Zip Code): <br /> 7 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin nt Sig a u ( Stamps) <br /> _ ^ <br /> 11 <br /> Approved ❑ Owner Given Initial 8�ge Fee) <br /> Adverse Determination \EnSu <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,0w er,Plumber <br />