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SANITARY PERMIT APPLICATION COUNTYQu� <br /> 7DIL11'a1R In accord with ILHR 83.05,Wis.Adm.Code .Ld <br /> — . <br /> STATE SAyy,,ITARY PE IT#/ <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than SC3 J5 J / <br /> 8'%x 11 inches in size. ❑ CZ1f revision to evious 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 PROPERTY LOCATION <br /> () JQ W ( c (T V) '/sRE '/a, S (C T40 , N, R b E(or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 3�i LOT- CdA <br /> CITY STATE ZIP CODE ONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> �'LS t� • `5 Or (oll— 39 0 H R <br /> 11. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> IIS�II ❑ State Owned VILLAGE OA Kul N IS R D <br /> ❑ Public ISI 1 or 2 Fam.Dwelling-#of bedrooms 3 BER(S) <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.XReplacement 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 9 Seepage Bed 21 ❑ Mound 30 ❑ SpecifyType 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.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 17. NALGRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Q P ELEVATION <br /> 50 1 S co (J • Lq -1 Z Feet b Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- App. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank .f - L <br /> Lift Pump 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 S ps) MP/MPRSWNo.: Business Phone Number: <br /> ao�tti�+< PK Ns 03p'c" i <br /> Plumber's Address(Street,City,State,Zip Code <br /> 2'116Q w(4 3-5 5-yt2 wk -jc6 <br /> COUNTY/DEPARTMENT USE ONLY <br /> Lj Disapproved Sanitary Permit Fee(Includes Groundwater Date IssuedIse Ing gent Signatu Stamps) <br /> Approved ❑ Owner Given Initial �^'�) surcharge Feel <br /> AdvDetermination -1/�}""j• <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />