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SANITARY PERMIT APPLICATION COUNTY r <br /> F:7:0_V1!LnHF In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITARY ERMIT <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ � / �� o �j�0 <br /> 8%x 11 inches in size. k o o 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 /> V/1V X_&87_ZJeR S L5 T31, N, R IG E (or <br /> PROPERTx OWhJE`S MAILING ADDRESS LOT# BLOCK# <br /> CITY,STA(T+�4/�tJ �/ Z�_QD ^,/ PONE NUN)BER <br /> 11 <br /> II. TYPE OF BUILDING: (Check one) UI to CITY : NEAREST ROAD <br /> State Owned VILLAGE �!1 f) RIP <br /> LQL <br /> ❑ Public � or 2 Fam. Dwelling—#of bedrooms EL TAXNUMBER( f1X <br /> Ill. BUILDING USE: (If building type is public,check all that apply) g 35-0/ <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 ❑ Seepage Bed 21Mound 30 ❑ Specify Type 41 EJHolding 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 /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (G Is/day/sq.ft.) (Min./inch) 9 a EVA7 ON <br /> 2� 2 • _L1 Feet Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xis8n Gallons Tanks Manufacturer's Name c ncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank <br /> Lift Pump 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 tier's Signature:(No S ps) MP/MPRSW No.: Business Phone Number: <br /> fc>t+00 RDF)e(Ns H 3qz& <br /> Plumber's Address(Street,City,State,Zip,Cp cid): <br /> 2'1 I&o <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee(Includes Groundwater a e asue Issuing Agen igna re(No a ) <br /> Approved E] Owner Given Initial //y�p�� ,,ssSurcharge Fee) <br /> Adverse Determination aW- M <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/(18) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />