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E SANITARY PERMIT APPLICATION <br /> o In accord with ILHR 83.05,Wis.Adm.Code COUNTY bArr02e— <br /> STATE SANITARY PERMIT#IajG- o <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than r/� 33 <br /> 8%z x 11 inches in size. ElCheck if revision 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 4NUMPERSUBDNSION <br /> ERTY LOCATION <br /> / J a] '%, S T �, N, R E (or <br /> PROPERTY OWNER'S MAILING ADQRESS LOT BLOCK# <br /> C�v STAT ( ZIP CODE PHONE NAME OR CSM NUMBER <br /> EG11. TYPE OF BUILDING: (Check one) TY NEA EST ROAD <br /> ❑ State LLAGE <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedroomsPARCELAX NU ( ) <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. IFTX�I( New 2. ❑ Replacement 3. El Replacement of 4. EJ 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 El Mound 30 ❑ Specify Type 41 [1 HoldingTank <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. 7. FINAL GRADE <br /> /�!� REQUIRE (sq.ft.) PROPO D q.ft.) ( 'als/day/sq.ft.) (Min./inch) / _ LEVATION <br /> 3W �� 5 -6) Feet 7 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 strutted <br /> Septic Tank or Holdin Tank <br /> Lift Pump Tank/Si hon Chamber <br /> Vlll. 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 Stamps MP/MPRSW No.: Business Phone Number: <br /> x� G�� �- L / 7/-5 ,?66 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater [Date issue Ise ' gent Signatur tamps) <br /> msµ ' �, <br /> ADDroved Surcharge Feel <br /> Owner Given Initial `y},il <br /> A Determination a <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safetyd Buildings Division,Owner,Plumber <br />