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SANITARY PERMIT APPLICATION COUNTY <br /> 7DILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> — s u rH e'4 <br /> ~ � STATES NIT RY MIT#loo 3`g' <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than CC I)LL//��__ yWy O O <br /> 8t%x 11 Inches In size. ❑ Check if revision o 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^7� PROPERTY LO CATION a <br /> Gal 1 Yoz ei i-) E'/a 6✓'/a, S � T30 , N, R � <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> X IG <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER. <br /> S(1ea. t.11t` S 2- �l o rn ✓ �. L� " <br /> 11 <br /> II. TYPE OF BUILDING: (Check one) CITY r NEAREST ROAD <br /> ❑ State Owned VILLAGE Q n l e�S C u 1 4 L�/ <br /> ❑ Public N 1 or 2 Fam. Dwelling—#of bedrooms EL A UMBE Yl <br /> III. BUILDING USE: (If building type is public,check all that apply) o o6- p-2 4 ab- 03 56-D <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 ❑ RestauranUBar/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. TYfPPE'OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. Ip New 2. ElReplacement 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 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 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REO IRED(sq,ft.) PROPOSED(sq.ft.) (Gals/day/sq.h.) (Min./inch) q ELEVATION <br /> 3©0 /o �O , 7Am / 3 Feet S Feet <br /> VII. TANK CAPACITY 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 /> Se tic k or H Idino Tank rZo i i 7 1 1 LAI I t° <br /> Litt Pump Tank/Siphon Chamber <br /> F-1 F1 F1 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility fo installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name Prin): Plu bar's S' nature (No tamps) MP/MPRSW No.: Business Phone Number: <br /> ds F ILLS 1r &0% <br /> Plumber's Address(Street,City,State,Zip Code): <br /> -78e5 Go <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater e e issued Issuin Agent Signature(No Stamps) <br /> yI, Surcharge Fee) <br /> Approved ❑ Owner Given Initial y{ ILU` /�'Y �_ 1 _ <br /> Adversetermin i n -ff / ��J / Gun l/ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />