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SANITARY PERMIT APPLICATION COUNTY <br /> DILHR In accord with ILHR 83.05,Wis.Adm.Code STATE SANITARY RMIT#o <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than )7 feV previous application <br /> 81/2x 11 inches in size. <br /> -See reverse side for instructions for completing this appI'lcati n. STATE PLAN I.D.NUMBER� <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. bY'6.L_o S 4 <br /> PROPERTY OWNER PROPERTY LOCATION <br /> l/alt S011 %AWIa, S 3 �o R I F <br /> V <br /> PROPERTY ER'S MAILING ADDRESS <br /> LOT# BLOCK# <br /> O <br /> CITY,STATE v ZIP CODE PHONE NUMBER/J S�, SUBDIVISION NAME OR CSM NUMBE S ! , /r <br /> S Ce O to t n � WJS' NEAREST ROA` Ur <br /> 11. TYPE OF BUILDING: (Check one) ❑State Owned viL�LAGE: �(11/ Oyt 64 F <br /> ❑ Public N 1 or 2 Fam. Dwelling-#of bedrooms // //'�� ['�f <br /> III. BUILDING USE: (If building type is public,check all that apply)qq3(o— 01—'-r <br /> 1 ❑ Apt/Condo 10 El Outdoor Recreational Facility <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 11 ❑ OutdooRestaur Recreational <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs <br /> ing <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 /> Repair of an <br /> A) 1. New 2. ❑ Replacement 3. ❑Tank Only of 4'❑ Exist ng System nnection of 5 ❑ Existing System <br /> System <br /> B) ❑ A Sanitary Permit was previously issued. Permit# — <br /> Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental <br /> Other <br /> 21 El Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 11 ® Seepage Bed 42 ❑ pit Privy <br /> 12 ❑ Seepage Trench 22 ❑ In-Ground 43 ❑ Vault Privy <br /> 13 ❑ Seepage Pit Pressure <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: FINAL <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC:RATE 6. SYSTEM ELEV. 7. E EVATION GRADE <br /> RE��tUIRIED(sq.ft.) PROPOSED(sq.tt.) (Gals/day/sq.ft.) // (MIn./Inch) q <br /> 4 S© I Feet Feet <br /> CAPACITY Prefab. Site Fiber- Exp <br /> oncreer. <br /> VII. TANK in allons Total #of Manufacturer's Name te Con- Steel Plastic App <br /> INFORMATION New istin Gallons Tanks structed glass <br /> Tanks Tanks r <br /> tic rHoldin Tank <br /> Litt Pum Tank/SI hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for stallation of the onsite sewage system shown on the attached plans. <br /> MP/MPRSW No.: Business Phone Number: <br /> Plumber's Name(Print): Plum er's Si nature: No mps) <br /> � r I.yt g(Oicr- O$ <br /> Plumber's r'p's Address( treat,City, tate,Zip Code): Q�S�J <br /> logs f 6 <br /> IX. COUNTY DEPARTMENT USE ONLY issuingfl Sign re N ps) <br /> Diss roved Sanitary Permit Fee(Inciudee Groundwater a e ssue <br /> Pp Surcharge Fee) _L <br /> Approved F-1OwnerGiven Initial I7�e <br /> Adv roe De ermin tion <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 />