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SANITARY PERMIT APPLICATION COUN r <br /> 70ILHR In accord with ILHR 83.05,Wis.Adm.Code Itu <br /> 7STATE SANITARY RMIT#oZb1g <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than C J 7i�y <br /> 8'%x 11 inches in size. ❑ Check it revlalo 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 PROP RTY LOCATION� qq ��77 <br /> G NS '/a ''/a,SLO TZ , N, R q E( ) W <br /> PR PERTY OWNER'S MAILING ADDRESS LOT# I.-t ) BLOCK# <br /> x Z3 <br /> CITY,STATEZIP CODE PHONE NUMBER SIn <br /> ❑ <br /> If. TYPE OF BUILDIN : (Check one) State Owned O CITY NEARES ROAD VILLAGE: <br /> -] Public 1 or 2 Fam.Dwelling-#of bedrooms' L UMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) Q - D's -"o`y- <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. ❑ New 2. �t[q�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 /> 11 Wseepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 LJ 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 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERI.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) p ELEVATION <br /> 50 Z b /• Feet /' Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #ot Prefab. Fiber- Exper. <br /> INFORMATION New ns!stiGallons Tanks Manufacturer's Name oncreta Con- Steel glace Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdin TankG <br /> Lift Pum Tank/Siphon 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 mps) MP/MPRSW No.: Business Phone Number: <br /> IWAii R/ -S w 3 Z� 15 $640Is <br /> Plumber's Address(Street,City,State,Zip code): {� W� - <br /> I 160 -'V 35 %EfD <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> isapproved Sanitary Permit Fee(includes Groundwater Date issued Issuing a Si n ure( o mps) <br /> Surcharge Fee) <br /> EApprov�sed]10wnerGiven Initial -4 13� COdv D t rmi ti n <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6395(formerly Plb{7)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />