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(� SANITARY PERMIT APPLICATION COUNTY <br /> iJ 0ILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> 6u C CAL: <br /> �ANITAR STATEERMIT#�:p/I/, I <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ E �56� OT `t <br /> 8'/z x 11 inches In size. Check It revisj6n to 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 /> PMR ERTY OWNER p Q PROPERTY LOCATION <br /> le. 5ela `G '/4 ''/4,S T� N, R S E (or <br /> PRO ERTY OWNEfi' MAILING A DRESS LOT# BLOCK# <br /> �/�1 � .f � <br /> CITY,STATE /077ZIP CODE _ PHONE NUMBER SUB IVISION N E OR CSM NUMBER <br /> c% v Laf 5 <br /> II. TYPE OF BUILDING: (Check one) CIN Q �� NE REST ROAD n� c <br /> State Owned VILLJOINAGE L <br /> ❑ N RIF: <br /> Public 1 or 2 Fam.Dwelling-#of bedroomsPARCEL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) /j /� 7K0 <br /> 1 ❑ Apt/Condo T <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. 17XyI(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-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 5Seepage 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 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> 3� REOUIR�Djsq.n.) PROPOS (s ft.) (Gals/day/sq.ft.) (Min./inch) ,- ELEV TION <br /> /2,? Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New iatin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tankor Holdina Tank <br /> Lift Pump Tank/Siphon 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: o Stamps) MP/MPRSW No.: Business Phone Number: <br /> ire G� OWZ)2,P67 <br /> Plumber's Address(Street,City,Slate,Zip Code): <br /> /7 //e/7 Lc <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sa itaryPermit Fee(Includes Groundwater Date IssuedIssuing Agert 'gnatur (No psi <br /> �y���, Surchangs Fee) -/� <br /> Approved El Owner Given Initial '-'`+tri, Fvy�J <br /> Adverse Determination -� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety8 Buildings Division,Owner,Plumber <br />