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SANITARY PERMIT APPLICATION r� <br /> 01 HR In accord with ILHCOUNTYR 83.05,Wis.Adm. Code G <br /> STATE SANITAAYPERMIT#/65 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than / //Gp/p '^ "J <br /> 8'%x 11 inches in size. ❑ C�eck If re Ion 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. <br /> PROPERTY OWNER PROPERTY LOCATION pp <br /> RE �Ri71r E V E7%, S �O T , N, R (9 E (or)(R <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 1' W 35_ Nle <br /> CIN,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 11. TYPE OF B ILDING: Check one CITY NEAREST ROAD <br /> ( ) State Owned VILLAGE: r -7 <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms XNUM <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. ❑ New 2.�Replacement 3. ElReplacement of 4. EJ 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 /> 11Seepage 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 PEW7 2.ABSC RP.AREA 3.ABSORP.AREA4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Galls/day/sq.ft.) (Min./inch) ELEVATION <br /> 3bQ . 62 3 Feet .fl Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name ConcrePrefab, Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holding <br /> Tank '1190 1L. <br /> Lift Pum 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 tamps) MP/MPRSW No.: Business Phone Number: <br /> 3 2G 7/S - iS <br /> lumber's Address(Street,City,State,Zip Code): <br /> 27'7(10 w� 3s' Wr951-62 til, S <br /> IX. COUNTY/DEPAR MENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Da eI ued Issuing Agent S nature(No ) <br /> Approved ElOwner Given Initial �7Surcharge Fee) o <br /> Adverse Determination '��" ` 0 <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 />