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MD211=HR SANITARY PERMIT APPLICATION COUNTYIn accord with ILHR 83.05,Wis.Adm.Code"e <br /> • �- STATE SANITARY PERMIT#) �� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than El ��635/J� <br /> 75� 4I <br /> 8%x 11 inches In size. Check if reviaio 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 <br /> glaLm tICkqf_t ''/a, S T N, R E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> p 0Rctk1R1K>7 . N 33 <br /> CITY,STATE I ZIP CODE PHONE NUMBER SU <br /> ocY,�. rJYH M 3 v <br /> 11. TYPE F BUILDING: (Check one) ❑State Owned n CITY <br /> 5L�r, NEAREST ROAD,C{`l'i <br /> WAY <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms Z1_ , �r <br /> A — ^�_ <br /> 111. BUILDING USE: (If building type is public,check all that apply)--- lJ �� -j <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 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 ❑ 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 DAY 2.A BSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> RE UpIRED(sq.ft.) PR POSED(sq.ft.) (G Is/day/sq.ft.) (M22in./inch) IC13 <br /> qELEVATION <br /> 3�� 08 % • r J - 1 Feet Ill? ,� Feet <br /> VII. TANK CAPACITY Site <br /> in allona Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding 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:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Ic o k I 3` z( IS c�- 5 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> `L w 3 S PE85_(ZFK W I - 54$q <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date' <br /> ❑ o `sJs�ue�_ <br /> Issuing AgegnatuIN ps <br /> owner Surcharge Fee) <br /> pprovetl Adverse eDetermin t' OC) ) <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />