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7 _ a SANITARY PERMIT APPLICATION COUNTY- <br /> 701r) <br /> In accord with ILHR 83.05,Wis.Adm.Code f At <br /> •mow STATENITARYtERMIT#COI$I <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than (71A <br /> 8%x 11 inches in size. 1:1 Check If revs on to previous application <br /> -See reverse Side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPE TY OWNER PROPERTY LOCATION <br /> CHgKL-CS 01wN)NG St '/4NIE1/4,S a4 T /i , N, R 15 E(or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> �RcSco i T LJ I O21 <br /> 11. TYPE OF BUILDING: (Check one) LJ State Owned O VILLAGE NEAREST ROAD <br /> l��7II <br /> 11 Public C](1 or 2 Fam. Dwelling-#of bedrooms— Nu <br /> 111. 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 /> 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. REl 3. Replacement of 4. ❑ Reconnection of 5.El Repair of an <br /> System �ystem 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 ❑ Specify 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 PER DAY 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REO IRED(sq.ft.) PROP SED(sq.ft.) (Gals//da /sq.ft.) (Min./inch) �y LEVATION <br /> QWn l� -(�- Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New isdn Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App. <br /> Tanks Tanks strutted <br /> Septic Tank or HoldingTank <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:(N tamps) MP/MPRSW No.: Business Phone Number: <br /> -211 <br /> AA 0 4 - 15 <br /> Plumber's Address(Street,City,State,Zip God": <br /> Z1160HkU 3S WEB5K W1 , 5*13 <br /> IX. COU /DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee <br /> (Includes Groundwater <br /> water a e ssu <br /> Issuing A an ignaNo Ste pa <br /> Approved E3 OwnerGiven 3urcharae Fee _I` <br /> AdveDetermination Q� � <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 />