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:, - SANITARY PERMIT APPLICATION COUNTY <br /> .... . <br /> t�ef�ir3rn In accord with ILHR 83.05,Wis.Adm.Code rp � rn� r <br /> STATE SANITARY PERMIT It <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than !Jy <br /> B"/z X 11 IDCheS In size. ❑ C if re is,on[�r vious application <br /> -See reverse side for instructions for completing this application. A..u� STATE PLAN I/D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. G I i �t) I 5 (0 — J <br /> 73 <br /> PR P TVOWNER PROPERTY LOCATION <br /> 2V1 r iSSC m ' ' a, S T��, N, R 1 � <br /> PROPERTY OWNER'S MAILING ADDR SS n t f Z LOT# BLOCK# <br /> I l -► � C wtt� U � .4 T1 <br /> CITY,STATE ZIP COD�[E PH NE NUM,B,ER SUBDIVISION NAME OR CSM Add <br /> rP ®d,�� <br /> Ur I t S`E8L O 7/S 'fes - 2 STDG d-d rTT 0�'� a <br /> Lj NEARESfj_ROAD <br /> II. TYPE OF BUIL ING: (Check one) E]State Owned viLTMLAGE ©a I` l.0, ��Y111 U F S LK, <br /> TI <br /> ❑ Public %1 or 2 Fam. Dwelling-#of bedrooms PAR ELTAXNUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) (f) o _ /I ...n,� ©Q <br /> 1 ❑ Apt/Condo C <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. TYii�IPEII OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. LCJ New 2. ❑ Replacement 3. 0 Replacement of 4. ❑ Reconnection of 5.El 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 L9 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.AB P.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. EI EVATION GRADENAL <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) <br /> Feet <br /> Feet <br /> VII. TANK CAPACITY Site Fiber- Exper. <br /> in allons Total #of Prefab. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> strutted <br /> Tanks rTanks _ <br /> Se tic Tank olding Ta 006 ( f <br /> Litt Pump Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility f installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(P int)' Plu bar's Signature: No mps) MP/MPRSW No.: Business Phone Number: <br /> �vtf SD 7�T G, <br /> Plumber's Add S eat,CiK te,Zip C¢Qet: ( 6 <br /> IX. COUNTY/DEPARTMENT USE ONLY Issuin t si n re( ps) <br /> Disapproved Sanitary Permit Fee Includes Groundwater ae sue <br /> � urcharge Fee) <br /> Approved ❑ Owner Given Initial <br /> r \ <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />