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1 00000" SANITARY PERMIT APPLICATION COUNTY <br /> 7DiLHR In accord with ILHR 83.05,Wis.Adm.Code -R; . .., <br /> �^ l�C <br /> STATE SANIT YPERMIT#131 <br /> 113T <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ /��c�0( TJ <br /> 8%x 11 inches in size. �4 <br /> hack if re cion to previous application <br /> -See reverse aide for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPE WNERPROPERTYLOCATION / <br /> 6k Y4 <br /> PROPEFftY 0 R'S MAILIN ADDRESS LOT# BLOCK# <br /> C ,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> -1_-60 <br /> II. TYPE F BUILDING: (Check one) 13 CITY N REST R AD <br /> State Owned VILLAGE //n <br /> ❑ Public 1 or 2 Fam. Dwelling-{�of bedrooms w <br /> 111. BUILDING USE: (If building type is public,check all that apply) �ij- -"7 C11 q- 01-6,70o <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. 0 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,,--PP(((ressurized Distribution Pressurized Distribution Experimental Other <br /> 11 IJLJ 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. PER'. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> .�/� REOUI D(sq.ft.) PROPOSED(aq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> "- + W. 5-Feet Feet <br /> VII. TANK CAPACITYin gallons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or HoldingTank <br /> Lift Pum Tank/Siphon 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 o Stamps) MP/MPRSW No.: Business Phone Number: <br /> L / <br /> Plumber's Address(Street,City,State,Zip Code): 7'' <br /> 1 Ivfyg <br /> OUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater ee esus Issui ant Signa (No Stamps) <br /> / r Surcnarile Feel <br /> pproved ❑ Owner Given Initial /05. c) <br /> I Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: / 7 <br />