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SANITARY PERMIT APPLICATION <br /> 7UILHR In accord with ILHR 83.05,Wis. Adm. Code COUNTY <br /> STATES ITARY P MIT#��.f�� <br /> s than (/Q-3� <br /> -Attach complete plans(to the county copy only)for the system,on paper not lesr7 <br /> 8%x 11 inches in size. ElCheck If revislort1b 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 /> PROEROWNER PROPERTY LOCATION <br /> S 7 T N, R l E (Or <br /> PROPERTY OWNER'S M (LING ADDRESS LOT BLOCK# <br /> �3rn' S of j5 <br /> CITY,STA E ZIP CODE PHONE NUMBER SUBDIVI ION NAME OR CSM NUMBER <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST RO <br /> State Owned VILLAGE: <br /> RA QF' <br /> ❑ Public 1 or 2 Fam.Dwelling--#of bedrooms L YAX Nu ) <br /> III. BUILDING USE: (If building type is public,check all that apply) ql_ss—n A-_�Drc <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. ❑ 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 /> 11Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ElHolding Tank <br /> 12 8 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 12.ABSORP.AREA3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROP_OS.�jE�D(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 50 ,� &V '95.13 Feet 5-7 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Expp. <br /> INFORMATION New Istin Gallons Tanks Manufacturer's Name oncrerefab Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank <br /> Lift Pump Tank/Siphon Chamber UFJ <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 ignature:(No ps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Co / <br /> X. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e e ue Ise g gent Signatyre(No Stamps) <br /> Approved ❑ owner Given Initial `,,�.i (� /�}(�Surcharge Feel -�'/G�// <br /> Adverse Determination /"5, `-"f <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD.8398(formerly PIb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />