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�.ILHR SANITARY PERMIT APPLICATION <br /> In accord with II-HR 83.05,Wis.Adm.Code COUNTv 5 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE SAANITARY''rPr7'evious <br /> IT#)5%q-78 <br /> 8'%x 11 inches in size. 11j 5S—See reverse side for instructions for completing this application. chat If revision application <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. STATE PLAN I.D.NUMBER <br /> PRO RTYOWNER - PR P Ty OC ION na 52 / `�( <br /> P P <br /> , Sdd T , N, R G� E (or <br /> PITY OWyER'S MAILING ADDRESS OT q / BLOCK# <br /> CITY�STATEVil <br /> ' ! ZIP CODE PHONE UMBER SUBDIVISION NAME OR CSM NUMBE <br /> � WHqS <br /> I1. TYPE F BUILDIN (Check one) ❑State OwnedciLryiAGE Y - NEAREST ROAD24? i <br /> ublic 1 or 2 Fam.Dwellin <br /> g of bedrooms_ q L u R <br /> Ill. BUILDING USE: (If building type is public,check all that apply) 8- (D <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: Specity <br /> IV. TYPE OF PERMIT: (C eck only one in line A. Check line B if applicable) <br /> A) 1. ❑ New 2.KRIeplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System ystem 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 21 ���❑ Mound 30 ❑ Specify Type 41 El Holding Tank <br /> 12 El Seepage Trench 22 yz5,ln-Ground <br /> 13 ❑ Seepage Pit / pressure 42 El Pit Privy <br /> 14 ❑ System-In-Fill 43 ❑ Vault Privy <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 13.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 1 ^c' REOU�21RED sq.tt.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVA ON <br /> VII. TANK CAPACITY 15- /Lf• Feet Feet <br /> in allons Total <br /> ' <br /> INFORMATION Prefab. Site Fiber- <br /> New istin Gallons Tankank s Manufacturers Name oncret Con- Steel Plastic Exper. <br /> Tanks Tanks structed glass App. <br /> Se tic Tank or Holdin Tank <br /> Lift Pump Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEME <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print) P be 's Signature:(No mps) MP/MPRSW No.: Business Phone Number: <br /> I tier's A dress( t ,City,State,ZIP Go,: I/i �" 5 �— l <br /> 'V 7/` W LO J <br /> IX. OUNTY/DEPARTMIENIT USE ONLY <br /> Lj Disapproved Sanitary Permit Fee(IncWtlea arountlwarer a e ssue Issuing ant Sign�re(No St <br /> Approved ❑ Owner Given Initial ��`` /'�s}urcharge Fee) P <br /> AdverseDetermination v�'w <br /> X. CONDITIONS OF APPROVALIREASONS 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 />