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SANITARY PERMIT APPLICATION <br /> 1311I.-HR In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITARY RMIT#IXX333 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than Nq&7 <br /> 8'fi x 11 inches in size. ❑ Check if revisio 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 /> PROPERTY OWNER PROPERTY LOCATION �" <br /> S 3 T N, R �cy E (or <br /> PROP TY O ER'S MAILING ADDRESS LOT# / / BLOCK# <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> - Czv. Co/ <br /> 11. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ❑State OWn@d 2 VILLAGE � 0 <br /> ❑ Public 1 or 2 Fam. Dwelling—#of bedrooms If- PARCEL TAXNUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) 012- <br /> 1 <br /> Id.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. TYPEOF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. V 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 EJSpecify Type 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 PERDAY 2.ASSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED .ft.) (Gals/day/sq.ft.) (Min./i ch) ELEVATION <br /> j Feet Feet <br /> VII. TANK CAPACITY Site <br /> INFORMATION In allons Total Of Prefab. Fiber- Exper. <br /> New Istin Gallons Tank Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Ta k5 Tanks structed <br /> Septic Tank or Holdin Tank <br /> Lift Pum Tank/Si hon 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 mps) MP/MPRSW No.: Business Phone Number: <br /> � > �i <br /> Plum is Address(Street.City.State,Zip Code): <br /> 7 <br /> X COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issu' g Agentftnatur Stamps) <br /> WApproved ❑ Owner Given Initialsurcharge Fee) <br /> Adv rmin ti n <br /> 1050 elf <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/66) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />