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SANITARY PERMIT APPLICATION COUNTY <br /> a01LHR In accord with ILHR 83.05,Wis.Adm.Code RUP_Ah5*� <br /> • om STATSANITA YPERMIT# <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than �I I?77 A)&q_S <br /> 8'%x 11 inches in size. ❑ Check it revision 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 r <br /> PROPERTY OWNER PROPERTY LOCATION ^ f, <br /> ` F11Vff\ /V0PD04SIRQM '/a '/a, S a[4 T70. N, R 440G <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> i s 830 S-k i h1 Ni:F_ <br /> CITY,STATE 20C+A mlV ;CODE PHONE NUMBER SU 1 ISIO NA E <br /> ss3� ;z gra 2y MV- � li <br /> CITY NEAREST OAD <br /> II. TYPE OF BUILDING: (Check one) ❑State Owned vILLAGE SCOT T I n <br /> ❑ Public b4 1 or 2 Fam. Dwellings of bedrooms PARCEL TAX NUMBERS) <br /> III. BUILDING USE: (If building type is public,check all that apply) av– <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 El Mound 30 ❑ Specify Type 41 EJ 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.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PER'.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> rn REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.11. <br /> (Mir diin�ch) ELEVATION <br /> St.) (� 448 0r s y A 8R,_7 Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New Istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> strutted <br /> Tanks <br /> �� Tanks <br /> Septic Tank or Holding Tank W <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'sy)Naame(Print): Plu ignature:(No Stam MPIMPRSW No.: 9 Business Phone Number: <br /> 0.4 <br /> Plum ' Address(Street,City,Stat%p C <br /> 1 . COUNTYIDEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Inclutles Groundwater ae asue Issuing gent Signatur o tam <br /> Suro rge Fee) _ <br /> &pproved ❑ Owner Given Initial �So /�j--t�. <br /> A ve a termin I n <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />