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NMI SANITARY PERMIT APPLICATION <br /> DIL IR In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> ELt <br /> STATE SANITARY PERMIT#�'1��•�(n <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than /S) <br /> 8%x 11 inches in size. ❑ c kiire�l n 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 /> PROPERTY OWNER PROPERTY LOCATION <br /> U '/4 ''/4, S T N, R ( E(or W <br /> RTYO <br /> PROP WNER'S MAILING ADDRESS LOT# <br /> 3c>2b CEN o • I 0 aL. 3 <br /> CITY,STATE ZIP CODE PFJONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> )Z D 0 z u S FIVEKrs S <br /> It. TYPE OF BUILDING: Check one CITY NEAREST ROAD <br /> ( > ❑State Owned VILLAGE F.K N aLow 1qu RQ - <br /> ❑ Public K1 or 2 Fam.Dwelling-#of bedrooms-7== <br /> Ill. BUILDING USE: (If building type is public,check all that apply) ;Z—,?/L4LJ'_ ar�— Got` <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. 1Z 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 /> 11SeepageBed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 16 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 12.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REO]�P�UUI)RptED(sq.ft.) PR(O,JP,OSED(sq.ft.) (G Is/day/sq.ft.) (Min./inch) ELEVATION <br /> 3 oo —I$o 1 rZ T u Feet % Feet <br /> VII. TANK CAPACITY - Site <br /> in allons Total #of Prefab. Fiber- <br /> to <br /> iber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or 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:(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> ( I(S 66- 415? <br /> Number's Address(Street,City,State,Zip Codef. <br /> U Rw WE6 -59 (- Sq?13 <br /> IX. OUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued se g gent Signs re(No Stamps) <br /> Approved ❑ Owner Given Initial y Surcharge Fee) ' <br /> Adverse Determination �--Yl J�.o'-�"Q <br /> X. C NDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-6388(formerly Plb87)(R.11/98) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />