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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code col Nrv� <br /> STAT NIT RY PERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than , -m6s� <br /> 814 x 11 inches In size. El Check it revision to 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. SK- <br /> PROPERTY OWNER rRERTION <br /> MA g\j S /aS 'ZZ T,�, N, R E (o W <br /> PROPERTY�O7W R'S MAILING ADDRESS BLO K#CI TATE ZIP CODE PHONE NUMBERME OR CSM NUMBER <br /> 1. 3 t� �-II. TYPE OF BUILDING: (Check one) NEA EST ROAD <br /> ❑State OwnedI�CD� 00 <br /> TnwN OF.❑ Public 1 or 2 Fam. Dwelling-#of bedrooms PARCEL TAX NUMBER(,) <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 ❑ 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 <br /> II OF 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 /> 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 /> 1 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 . SYSTEM ELEV, 7. FINAL GRADE <br /> REO I1p0RED sq.ft.) PRO OS <br /> (sq.ft.) (Gals ay/sq.ft.) (Min./inch) ELEVATION <br /> 3 •bZ Feet l0 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exp . <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App. <br /> structe <br /> Tanks Tanks <br /> Septic Tank or Holding Tank (c)V) <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 Stamps) MP/MPRSW No.: Business Phone Number: <br /> )�s 3 26 l� `�(ob- 5 <br /> P umber's Address(Street,City,State,Zip ode) <br /> 2 WY 25 \J6e5L91, WLJr13 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes GroundwaterOffalssue Issuin ant Sig at re o Stamps) <br /> t� SurSharge Fee) / _ \ <br /> Approved ❑ Owner Given Initial t`(\ <br /> Adverse Datermin tion T� LJ Cl LJ co <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBa6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,C wrier,Plumber <br />