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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couN <br /> STATESANITARY P�RMITq� y�7_ <br /> Attach-complete-placa(to the county copy only)for the system,on paper not less than dMSrr/\ <br /> 4 1 <br /> e'6 X 11 Intfitr <br /> ea' T'Slie.�.�_y'- ❑CAe�k Hrevid 6previoue application <br /> L_.__.-S6efBVBr3e side for instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT I ORMATION rfll.EASE PRINT*LL 1NFOR1�AT1ON. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> %4 v)YV' 1/a,S T qQ N, R 6 E (orQ <br /> PRO M OWNER'S MAILING ADDRESS LOT BLOCK# <br /> D . 3LVn- <br /> Cl-V,STATE dIRCOtfE' FHOl�Q, BER"/<Jt <br /> ::._ <br /> II. TYPE OF BUILDING: Check one) 3S'7 CITY N REST ROAD <br /> ( ❑State Owned l VILLAGE G . <br /> �I <br /> ❑ Public K1 or 2 Fam. Dwelli of bedrooms— <br /> III. BUILDING USE: (If building type is pqbficheck all that apply) 13)- 7 <br /> - �� <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall C 6 ❑ je"l <br /> I Flaciill /7Nu ing H,��'e 1 ❑ uJerStatfon/Car <br /> Recreational Facility <br /> 3 ❑ Campground J/+i j QCI>6et�Itl� psN1`1, "m r'_) ant/Bar/Dining <br /> 4 ❑ Churcl Kiiool 8 � c6i]e Home Park 12 ❑ Se 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. XNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Aepairof aa� <br /> System System Tank Only Existing System f Entisting'Sy*iVt -, <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 �SeepageBed 21 El Mound 30 El Specify Type 41 ❑ Holding-TVk_ <br /> 12 Seepage Trench 22 ❑ In-Ground 4? 'fjit Pnv/ <br /> 13 El Seepage Pit Pressure 43 Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 12.AOSORP,AREA 3. SORP�A 4. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> �y REO IRED(sq.ft.) PROPOSED sq.ft.) (Galls/day/sq.ft.) (Mimi./inch) ELEVATION <br /> V r 0 az_ 1 Feet Feet <br /> Site <br /> VII INFORMATION IwTANK P Ilbl s "'T'StaIY #of la nufscturer'sName Prefab. Con- Steel Fiber- Plastic Exper. <br /> New istin Gallons Tanks oncret strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holdin Tank r I <br /> Li11Pum Tan hon Chem r <br /> j 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 tamps) MP/MPRSW No.: Business Phone Number: <br /> 0/K 1946- 1S <br /> umber's Ad rens(S reet,City,State,Zip Co ): <br /> IX. COUNTY/DEPARTMENT USE ONLY - <br /> Disapproved nitary PermitFee(imlu Groundwater Date ssue IssuingAge Si psi <br /> _ <br /> APProved ❑ Surcharge Fee)) <br /> Owner Given Initial � (3 tD , LQ _ (i� 1 I �, �, Apr.. <br /> Adverse ion <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> r <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />