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77- SANITARY PERMIT APPLICATION <br /> >DILHR In accord with ILHR 83.05,Wis.Adm.Code couNTv^ <br /> STATE SANITARYr <br /> IIP <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than 39qMIT#!�)(055" <br /> ❑ % <br /> 8%x 11 Inches In size. CheccT< f 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. S sq– -2031-7 <br /> PROP RTY OWNER PROPERTY LOCATION <br /> '/4 '/4, S Jf T�D, N, R E (o <br /> PROPERTY OWNER'S MAILING ADDRE LOT# BLOCK# <br /> CITY,$T E ZIP CODE PHONE NUMBER— SUBDIVISION NAME OR CSM NUMBER <br /> It. TYPE OF BUILDING: (Check one) ❑State Owned VILLLLAGE N REST ROAD9j# OF <br /> ❑ Public 1 or Fam. Dwelling–#of bedroomsFAMUSAA MB R( ) <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. El New 2. ldl Replacement 3. El Replacementof 4. El 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 Oth,,,e���,,,r{{{ <br /> 11 ❑ Seepage Bed 21 El Mound 30 ❑ Specify Type 41 Holding Tank <br /> 12 ❑ Seepage Trench 22 ElIn-Ground42 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 14. LOADING RATE 5. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Feet Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in aligns Total #of Prefab. Fiber- Exper. <br /> INFORMATION New Istin Gallons Tonka Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdin Tank <br /> Lift Pump 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:(No Stamps) MP/MPRSWNo.: Business Phone Number: / <br /> Plumber's Address(Street,City,State,Zip Code) <br /> A/C <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date IssuedIssuing Agent Signature(No Stamps) <br /> Approved � Surcharge Fee) <br /> Adverse❑ Owner Given Initial II�0 ryy� <br /> Determination; <br /> min I n i V lJ <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />