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SANITARY PERMIT APPLICATION COUNTY <br /> Evim-9HIn accord with ILHR 83.05,Wis.Adm.Code I <br /> c vT <br /> STATE S,4NITARV PERMIT#jj <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8%x 11 inches in size. Chec <br /> ❑ L k '�`.io� <br /> k If revisi 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 <br /> 0M 5 '/a �� '/e, S 2 T N, R_ 4 E(or)OW <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> CITY,STATE ZIP CODE PHONE NUMBER <br /> t M� S -'f HcKEs <br /> If. TYPE OF BUILDING: (Check one) CIN NEAREST ROAD <br /> State Owned VILLAGE LpN� IIdE <br /> ❑ Public 1 or 2 Fam. Dwelling,#of bedrooms A L R( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) 3`��.- <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: (Chet only one inline A. Check line B if applicable) <br /> A) 1. E1New 2. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System ystem 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 yS(Seepage Bed 21 El Mound 30 El SpecifyType 41 El HoldingTank <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 PEF7 2,ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RA <br /> 3� TE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REO IRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 9 l.� (, ELEVATION <br /> p(o t '-1 Feet 19 .Z Feet <br /> VII. TANK CAPACITY oncret <br /> Site <br /> in altons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistfn Gallons Tanks Manufacturer's Name refab.e Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdin Tank =- <br /> Lift Pump Tank/Siphon Chamber <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 /> fcH o 1r)S _2Ll5 $(�6- y(1> <br /> Plumber's Address(Street,City,State,Zip Code): <br /> LT4>0 iqvjWEBSTEjz, L.) ) . 6`103 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit FeeuncludesGroundwater ae ssue Issuing Ag tSign lure IN St mpsI <br /> Surcharge Fee) a <br /> 1. <br /> Approved ❑ Owner Given Initial �j} low �.)j--) / <br /> Adverse Determination --fl' <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 8 Buildings Division,Owner,Plumber <br />