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_ SANITARY PERMIT APPLICATION <br /> r.n�HR In accord with ILHR 83.05,Wis.Adm.Code CO NTY <br /> U <br /> STA E SANIT RY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 646 1S <br /> 8%x 11 inches in size. ❑ Check if revision to previous application <br /> —See reverse side for instructions for completing this application. STA E PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> L& I✓L`�'/a '/4, S T N, R E(or W <br /> PRO ERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> T / <br /> CITU,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ❑State Owned VILLAGE <br /> ❑ Public �or 2 Fam. Dwelling-#of bedroom A CEL TAXNUM ER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) W m- oa 1 <br /> 1 ❑ ApVCondo <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. T�F PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> ystem 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 ❑ 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 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6 SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVP�TION <br /> 3w ��Q -3 ai - -(v Feet I l,00-0eat <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon 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): Plumb ' e:(No Stamps) MP/MPS R§3"o.: Business Phone Number: <br /> � 50-7-) <br /> Plumber's Address(Street,City,State,Zip Code): <br /> /(P -7 <br /> IX. COUNTY/DEPARTME USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a ssue Issuin nIS'pnet r ( oSt s) <br /> j.t/� ur barge Fee) 11^I 1 <br /> Approved ❑ Owner Given Initial -.Ctf'J <br /> Adverse Determination <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,0 net,Plumber <br />