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SANITARY PERMIT APPLICATION COUNTY <br /> .DILI-IR In accord with ILHR 83.05,Wis.Adm.Code n <br /> STATE SANITARY PERMIT#ao�$i li I. <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ 17JG�I, '/T <br /> 8'%x 11 inches in size. chec 1f revlalo;tto 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 iI / <br /> '/4 '/4,S 1 T , N, R 1(p E(oCW <br /> PROP RTYOWNER'SMAILINGADDRESS LOT# BLOCK# <br /> CNALEY P2 <br /> CITY,STATE I ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> MPLS . 11 ( MrluwDBE&iA sa ?Lgrf <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ❑ State Owned O VILLAGE: Y/ 9,- <br /> 7 0❑ tj <br /> Public � or 2 Fam.Dwelling-#of bedrooms N ) I T/rrGr r <br /> III. BUILDING USE: (If building type is public,check all that apply) ���I j— 0`� 0t)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: (C eck only one in line A. Check line B if applicable) <br /> A) 1. ❑ New Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System ystem 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 Oth���err,�""" <br /> 11 El Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 4Holding Tank <br /> 12 ❑ Seepage Trench 22 ❑ In 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 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.tt. Min./in ELEVATION <br /> 300 Feet Feet <br /> VII. TANK CAPACITY Site <br /> ingallons 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 /> Se tic Tank or Holdin Tank I <br /> Lin Pum Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): I Plumber's signature:(No Stam MP/MPRSWNo.: Business Phone Number: <br /> a 3 2� �6- s <br /> lumber's Address(Street,City,state,Zip Co y <br /> Z (00 1 i&SME Owl, sqm <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date issued Issuing gent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial surcharge Fee) <br /> Adverse Determination <br /> X135.0"0 S-b-93 <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 8 Buildings Division,Owner,Plumber <br />