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SANITARY PERMIT APPLICATIONrZ751!L,HrR,! <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTYf n <br /> STATE SANITARY PERMIT#132S61 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than Ikk%Sgp,- <br /> 8%x 11 inches In size. ❑ Check if 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. <br /> PROPERTY OWNER PROPERTY OCATION <br /> KENX5'5 '/4 /4, S 3 T_ N, R It E(or <br /> PROPEGRTY OWNER' MAILING ADDRESS LOT# BLOCK# <br /> 1� MALAW. AUJ <br /> CITU,STATE ZIP CODE PHONE NUMBER SUB (VISI NAME OR CSM NUMBER <br /> It. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> state Owned VILLAGE 1JaN LM O <br /> JPAN R;1 <br /> ❑ Public kl or 2 Fam. Dwelling-#of bedrooms <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 ❑ 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.,9 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 RSeepage Bed 21 ❑ Mound 30 ❑ SpecityType 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 Ej 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEMELEV. 7. FINAL GRADE <br /> RE UIRED(sq.ft.) PR POSED(sq.ft.) (Gel /day/sq.ft.) (Min./inch) Q ELEVATION <br /> I . 19• Feet O Feet <br /> VII. TANK CAPACITY Site <br /> In ellona Total TV. <br /> Prefab. Fiber- Exper. <br /> INFORMATION New antiln Gallon. Tanks Manufacturer's Name on rate Con- Steel glass Plastic App <br /> Tanke Tanks strutted <br /> Septic Tank or Holdin Tank �� <br /> Lia 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 /> Plumber's Name(Print): Plumber's Signature:(Nopa) MP/MPRSW No.: Business Phone Number: <br /> ,p 0Q01c D 305 �► 5' 66 - `( 15 <br /> lu -1 AddO s(SVeet,Clly, M,LIP C0tl 'EB lF—� <br /> IXCOU/NNTYIDEtPAVoRT ENT USE JONLY <br /> Disapproved anitary PermitFso(Includesoroundwater Date IssuedIss g gent Signat a(No Stamps) <br /> surohergs Fes) <br /> pprovad ❑ Owner Given Initial ( oto <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: V <br /> SBD-6398(formerly Pib-87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety d Buildings Division,Owner,Plumber <br />