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SANITARY PERMIT APPLICATION COUNTY <br /> 77UILIAR In accord with ILHR 83.05,Wis.Adm.Code _C <br /> -TT- <br /> STATE SA TARY RERMIT#13 A519 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than pgbur) <br /> 8%x 11 Inches In size. ❑ Check if revisiorYl"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 /> '/a '/a, S T �, N, R is E(o <br /> PROPERTY OWNER'S MAILING A,DpDRESS m/ LOT#/1 BLOCK# <br /> 7O O f 've. uV troo,-�• ( �f <br /> CI STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> (OOT K mrJ 5 <br /> If. TYPE OF BUILDI : (Check one) CITY NEAREST RO D <br /> State Owned VILLAGE �a - <br /> ❑ Public X1 or 2 Fam.Dwelling-#of bedrooms PARCEL TAX NU ER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) 3_y ao-7.,- C3-Oct) <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. TYP OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1.N 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�-P essurized Distribution Pressurized Distribution Experimental Other <br /> 11 {^I 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 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV, 7. FINAL GRADE <br /> 3oQ REO(J(R�ED AREA <br /> ft.) PROPOSED(sq.ft.) (Gals/day/sq.ff.) (Min./inch �� E EVATION <br /> llTllL (2S} n� (6) Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons of Manufacturer's Name oncrete Con- Steel glace Plastic App <br /> Tanks Tanks structed <br /> nk or Holdin Tank �Sa IC <br /> ift Pum nLk I hon Chamber ~IfJ tl �I <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the #site sewage system shown on the attached plans. <br /> Plumyer's Name(Print): lu is Signatur : o Stamps) MP/MPRSW Ni Business Phone Number: <br /> Nets oer � @e � 57 <br /> Plumber's Address IS ee,City.S te,Zip <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> Disapproved I Sanitary Permit Fee includes Groundwater latessue Issuin Agent Signature(No Stamps) <br /> f r <br /> Approved surcharge Fes) <br /> Owner Given Initial <br /> Adverse Determination lofC� <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 />