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�DILMENEWMENNIIII HR SANITARY PERMIT APPLICATION CODNTY ��� <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> �° •""•^�"�� STATE NITARYP RMIT#/a83gp <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than 114�4� <br /> ❑ Check If revision previous application <br /> 8%X 11 inches in size. STATE PLAN I.D.NUMBER <br /> -See reverse side for instructions for completing this application. -a l <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. � <br /> PROPERTY ER PROPERTY LOCATION %�,n <br /> C G` Z �'/4 t/4, S I T YV, N, R ! E (o <br /> C r r• CKr ° r BLOCK#� <br /> PROPERTY NER' MAILINGADDRESS LOT# <br /> C0 ? Al A <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> S .V Vr �?° / NEAREST ROA <br /> it. TYPE OF BUILDING: (Check one) ❑ State Owned O viLTMiAGE; �0 Z � P� <br /> ti�Public ❑1 or 2 Fam.Dwelling-#of bedrooms— L NU R( ) <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 /> 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 3 El Campground 12 ❑ Service Station/Car Wash <br /> 4 Church/School 9 Off ice/Factory <br /> Home ark 13 ❑ Other: Specify <br /> 5 Hotel/Motel <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> r of an <br /> A) 1. New 2. Replacement 3. ❑ Replacement of 4.0 EXfgo nnectigtem 5.❑ ExisRepting System <br /> System System Tank Only 9 y <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 /> Mound 30 El Specify Type 41X Holding Tank <br /> 21 <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. fMin RATE 6. SYSTEM ELEV. T ELEVATION <br /> GRADE <br /> REOUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) ( Feet Feet <br /> CAPACITY Prefab. Site Fiber- Exper. <br /> VII. TANK in allons Total #of Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> INFORMATION New istin Gallons Tanks structed <br /> ( 1 <br /> Se tic Tenk or Holdin Tank Tanks Tanks C <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 /> MPIMPRSW No.: Business Phone Number: <br /> Plumber's Name(Print): P s Signal ur :(No Stamps) — <br /> \\ <br /> P umber's A dr (Street, ity,State,Zip Code): <br /> Sqr <br /> IX. COUNTY/DEPARTMENT USE ONLY Issu gent Signatur No Stamps) <br /> Disapproved Sanitary Permit Fee llncludea Groundwater aessr^u�e <br /> Surcharge Fee) /a tj <br /> Approved C1 Owner Given Initial co <br /> A v r In Ion <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 />