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SANITARY PERMIT APPLICATION COUNTY <br /> FZ(�Y mHR In accord with ILHR 83.05,Wis.Adm.Code <br /> • �� STATV <br /> E$A�ITARY, IAMIT#/gnbq <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ll// U <br /> 8'fi x 11 inches in size. ❑ Check if revlalo 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 /> PROPERTY OWNER PROPERTY LOCATION J <br /> G I E v � ''/4,S ;U T ?, N, R E (or) <br /> PROPERTYOWNER'SMAILING ADDRESS LOT# BLOCK. <br /> S CAka L L►v <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBERn <br /> ST• �flUt° M S !l CITY �lF <br /> EAREST ROAD <br /> If. TYPE OF BUILDING: (Check one) ❑State Owned /� VILLAGE K.L . NG <br /> El Public 1 or 2 Fam. Dwelling-#of bedrooms — PA Ax MB ) <br /> III. BUILDING USE: (If building type is public,check all that apply) -,�o- <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. ❑ 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 /> 11 l)q 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 13.ABSORP.AREA 14. LOADINGRATE 5. FERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) LEVATION <br /> 3 0(? $ O ` r f p Z -0 Feet Feet <br /> VII. TANK CAPACITY Site <br /> in al Ions Total #of auPrefab. Fiber- Expp. <br /> INFORMATION Concrete strutted glass <br /> Manufacturer's Name Con- Steel Plastic <br /> New istin Gallons Tanks App. <br /> T nks Tanks <br /> Be tic Tank or Holl ina Tank <br /> Lift Purno Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,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 mps) MP/MPRSW No.: Business Phone Number: <br /> Ic R Ki S 3 Z� iS �(20(S <br /> Plumber's Address(street,City,State,Zip Cod <br /> 2-1'76o w 3 3T6iz W , Sy893 <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved Sr�itBiP�er Fee(Isurcharge Fee) ter Issue issuing Agenl Si eture oS p <br /> Approved ❑ Owner Given Initial �( _1 rs5-'\ <br /> Adv Determination[ 00 <br /> X. 6ONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />