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SANITARY PERMIT APPLICATION <br /> la_ MOMMOMM4 DILHR In accord with ILHR 83.05,Wis.Adm.Code coyglTv)� <br /> STATE SANITARYP RMIT# 132S5L1 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than (to-1 5�I) <br /> 8'%x 11 inches in size. ❑ Check if revision to previous 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 /> PRQPERTY OWNER PROPERTY LOCATION <br /> '/4 Ys,S T N, R E (orrC <br /> PROP RTY OWNE 'S MAILING AD RESS LOT# BLOCK# <br /> �t 14h-, ,_5, <br /> CITY,STATE ZIP COD PHONE NUMBER SUB IVISION NA ME OR SM NUMBER <br /> /// li - <br /> II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD <br /> ❑ State Owned VILLAGE: /.//L,�/� <br /> ❑ Public 1 or 2 Fam.Dwelling-#of bedrooms REL UMBERO /" <br /> III. BUILDING USE: (If building type is public,check all that apply) O LO-Q I <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. VOW 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 Seepage Bed 21 ❑ Mound 30 ❑ SpecityType 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 PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERI(Mi .RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> -L{/ REQUI D(sq.ft.) PROPOSED sq.ft.) (Gals/day/sq.ft.) n./inch) 76 <br /> Q// o EVATION <br /> /'7'` a Feet 7 ZI Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or HoldingTank <br /> Lift Pum Tank/Si hon 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 Signa//tore:(N mps) MP/MPRSW No.: Business Phone <br /> Phone Numbeerr: <br /> (/+/•sem / !�J /vtd" <br /> umber' Address(street,City,State,zip Code): <br /> 0� 11-/1 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved SanitaryPermit Fee includes Groundwater [Date Issued Issu Agent Signeamps) <br /> Surcharge Fee) <br /> pproved ❑ owner Given Initial �\�c� 0� <br /> Adverse r In VJ <br /> CONDITIONS OF APPROVALIREASONS 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 />