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17- "'1 SANITARY PERMIT APPLICATION COUNTY <br /> DILIn accord with ILHR 83.05,Wis.Adm.Code <br /> �� s• � STATESANITAR ERMIT#� � <br /> J Ji <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 5 <br /> 8'%x 11 inches in size. 1:1 Check if revislon 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 /> PROPERIY OWNER PROPERTY LOCATION <br /> /)"14 ),/ /4, S 9 T5/614, 191 E (o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> `7 �2i�7= <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> II. TYPE O B ❑ State Owned <br /> ILDING: (Check one) CITY NEAREST ROAD <br /> VILLAGE K� 7Ac�t/Cfi <br /> ❑ Public 1 or 2 Fam.Dwelling-#of bedrooms— L MB pp (('��11 <br /> 111. BUILDING USE: (If building type is public,check all that apply) �L�` `O V O— V r �� <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 it applicable) <br /> A) '. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> stem 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 /> No��-Pr ssurized Distribution Pressurized Distribution Experimental Other <br /> 11 I Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12Seepage 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 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERI.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) r7 �EELEVATION <br /> • / Feet 7 S Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> strutted <br /> Tanks Tanks <br /> Se tic Tankor Holdin Tank - <br /> Litt 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): Plu aSign re: Stamp MP/MPRSW No.: Business Phone Number: <br /> N (G/ t�7 s a��l d G <br /> Plumber's Address(Street,City,State,Zip Code): , <br /> 8 6z,- <br /> X. OOUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary permit Fee(inciudurchGrge Fun,water a e ssue Issuing 9 ant Signatuurree(No Stamps) <br /> 1)4pp <br /> roved ❑ Owner Given Initial C IG- .F 1 } /��' y1 <br /> A verse Determination —t` �.l �� t <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 />