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SANITARY PERMIT APPLATIO rim <br /> IC <br /> E <br /> In accord with ILHR 83.05,Wis.Adm.Codecou rr �rnln <br /> -Attach complete plans to the court Co - STA ANIT Y PERMIT# <br /> p p ( county copy only)for the system,on paper not less than � � aln n 0 <br /> B%X 11 IDCheS In SIZ@. heck if revision to previous application <br /> -See reverse side for Instructions for completing this application. STA E PLAN I.D.NUMB R <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. 1 <br /> PROPE TYOWNER PROPERTY LOCATION <br /> Me (0?44ELL % %, S Z1 T37, N, I E (Or <br /> PROP RTYoOWNER'S AILING AD RESS LOT# ` BLOC # V` <br /> CITY,STATE 33 ZIP CODE PHONE NUMBER SUBDIVISION ME OR CSM N MBER (]- <br /> (K 1 IS Z?- � t- I'll <br /> 11. TYPE OF BUILDING: Check one CIN NEAR ST ROAD <br /> ( > State Owned �/ AG <br /> VILLE' <br /> El Public 1 or 2 Fam. Dwelling-##of bedrooms L1 PARCEL TAX NUMBER(S) <br /> 111. 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 ❑ Res aurant/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: (Checkonlyone in line A. Check line B if applicable) <br /> A) 1. El New 2. XReplacement 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 El Seepage Bed 21 �I Mound 30 L1 Specify Type 41 El HoldingTank <br /> 12 El SeepageTrench 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 DAI 2.ABSORP.AREA 3.ABSORP.AREA4. LOADING RATE 5. PERC.RATE 6. YSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> UI <br /> 300 ISv 2 —_ ItO, 7— Feet Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- teel Fiber- Plastic Exper. <br /> INFORMATION New istin Gallons Tanks Concret glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank <br /> Litt Pump Tank/Siphon Chamber .500 <br /> Vill. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached pi ans. <br /> Plumber's Name(Print): Plumber's Signature:(No S ps) MP/MPRSW No.: Business Phone Number: <br /> t,NflKn 14604114s <br /> P mber's Address(Street,City,State,Zip de <br /> Z 6o w 35 w6e5rl 3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee includes Groundwater Date Issued Issuin g tsi n e N mps) <br /> Approved ❑ Owner Given Initial r „ rcherge Fee) <br /> Adverse Determination ���LJ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Own r,Plumber <br />