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DI�HR SANITARY PERMIT APPLICATION COUNTY. <br /> __ In accord with ILHR 83.05,Wis.Adm.Code �«rnQ <br /> �M STATE SANITARY ERMIT#Qii , s <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8'%x 11 inches in size. ❑ Check if revlsi to previous application <br /> —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. Sgq C ISS <br /> PROPERTY OWNER PROPERTY LOCATION <br /> /('ttJW '/4 SE '/4, S T tjld, N, R <br /> PROP RTY OWNER'S MAILING DRESS LOT# /� /^ ^{'/b BLOCK#, . ' <br /> c //7 b *"4 <br /> CITY,S TE ZIP CODE PHONE NUMBER SUBDIVISION NAME 0 CSM NUMBER <br /> tit- � i � y <br /> Lj CITY a NEAREST ROAD 'n <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE; of,fZ ,,'c <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms EL UMB <br /> 111. BUILDING USE: (If building type is public,check all that apply) Dc-�0ac - <br /> ba o <br /> 1 ❑ ApVCondo <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. ❑ 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 ❑ Seepage Bed 21 ® Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 El SeepageTrench 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.ASSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(s( .ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 9 ELEVATION <br /> rn �- 3 -2 7j < �• 7 Feet Feet <br /> VII. TANK CAPACITY Site <br /> in ellona Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons of Manufacturer's Name ConcreteCon- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank I Qb0 <br /> FT LL_ <br /> Lift Pum Tank/Si hon Chamber, tJz C- <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,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/MPRSW No.: Business Phone Number: <br /> Plumber' <br /> dresslStreet.iCity,State,zip Code): <br /> Wqba7' <br /> IX..COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater ae saue Issuin gent Signature(No Stamps) <br /> r/r� aurcherge Feel <br /> Approved ❑ Owner Given Initial �' /V 0.0 <br /> Advent <br /> D termin tin lJ �lJ 1 <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 />