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SANITARY PERMIT APPLICATION COUNTY <br /> 70ILHR In accord with ILHR 83.05,Wis.Adm.Code & <br /> momma STATE SANITARY PERMIT# 7�7 <br /> —At)ach complete plans(to the county copy only)for the system,on paper not less than ❑ ( t 50)�� <br /> 8' X 11 inches In size. Check If revision to pre ous application <br /> –See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATIO�N�r–PLEASE PRINT ALL INFORMATION. <br /> PROPERTY <br /> OWNER <br /> ,k^ Crh.Tn'� PRION <br /> OPERTY�SEOC J�S T ( , N, R (S E (or W <br /> PROPERTY PW�V'- `MA`ING ADDRESS LOT# 7J4 BLOCK <br /> CITU,STATE �\ 51P�0_DE PHONE NUMBER:��' SUBDIVISION Ni ME OR CSM NUMBER <br /> Il. TYPE OF IIILDING: Check oQVOeG)J(, CITY TYSII CG�j NEAREST ROAD <br /> ( State Owned n VILLAGE Sw 1� Hw� 35 <br /> ❑ Public X1 or 2 Fam.Dwellings of bedrooms iC u FR(3) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo <br /> 2 El Assembly Hall 6 El 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. ElReconnection 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 /> 11Seepage Bed 21 ElMound 30 ❑ SpecifyType 41 ElHolding Tank <br /> 12 F 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 AREA <br /> ft.) PROP^OOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 3ov Ir'1 .)Z �O� /(oD q•i Feet TS Feet <br /> CAPACITY <br /> VII. TANK 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 /> Tanks Tanks structed <br /> Septic Tankor HoldingTank C <br /> Lift Pum Tank/Sipon <br /> 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: NOS mps) MP/MPRSW No.: Business Phone Number: <br /> z L}S Tzogxti,,. <br /> Plumber's Address(Stre ,City,S te,Zip Code): <br /> 2` .1Fic� t�wr `3WEBSiER w� S`($`�3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes <br /> Groundwater a e ssueq Is ng Agent Signet (No Stamps) <br /> Approved ❑ Owner Given Initial �0 <br /> Adverse rmin i n lJ t <br /> CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/98) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />