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SANITARY PERMIT APPLICATION <br /> SDI&.HR In accord with ILHR 83.05,Wis.Adm.Code couNnr <br /> .ernes —� <br /> STATE NI TA ERMIT#/C7 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �A�I���//G__t(J/(�1,��� D <br /> 8'%x 11 inches in size. ❑ CFeck if revisi to previous application <br /> -See reverse Side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROP RTY``L'O'''C��ATION <br /> E. 00 Q VE G �'/a.J(/� %,S Z- T , N, R I y E(G <br /> PROPERTY OWNER'S MAILING ADDRE LOT# BLOCK# <br /> os-1 K)LLES KE R <br /> CITY,STATE ZIP CODE PHONE NUMBER .f�(� <br /> 4. L554 L V <br /> It. TYP OF BUILDING: (Check one) ❑State Owned CIT AGE Y I N REST ROAD <br /> ll <br /> ❑ Public �c or 2 Fam. Dwelling-#of bedrooms L ER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) o�—Q CC <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. eplacement 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.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq ft.) (Galls/day/sq.ft.) (Min./inch) �7 ELEVATION <br /> ( Q e l?Z 3 s° L Feet + 3 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 /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank <br /> Lift 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: No mpe) MP/MPRSW No.: Business Phone Number: <br /> lu tier's Address(Street,City,G 0e,Zip Codb): �� ���� � - <br /> Z G <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(1ncIWe9 Groundwater Mate Issued <br /> Issuing gpntSign ture( oamps) <br /> Approved ❑ Owner Given Initial LL_ surcharge Fee) fir(/ /// <br /> Adverse Determin i n I�J ' �'" ` <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 />