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SANITARY PERMIT APPLICATION COUNTY <br /> t2N E <br /> STATEANITAR <br /> 70IL_ HR In accord with ILHR 83.05,Wis.Adm.Code <br /> ERMIT#ISM <br /> 8%X 11 Inches In size. Check if revi n 7 <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ❑ usgos <br /> 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 P OPERTY LOCATION <br /> 1- 1 <br /> ug C j E(�L '/a C,`_3%, S L.� r, <br /> _. T N, R E(or(w) <br /> PROPER OWNER'S MAILING ADDR OT# BLOCK# <br /> 2 Z A � - <br /> CITY,STATEZIR SIj1oDE PHONE NUMBER SUBDDIIVISION NAME OR CSM NU ER ) . <br /> II. TYPE OF BUILDING: (Check one) [JState Owned VILLAGE NEAREST ROAD <br /> ❑ Public A or 2 Fam. Dwellingof bedrooms— L /BEAR( <br /> I <br /> 111. BUILDING USE: (If building type is public,check all that apply) , —[,f 500- 0 -)-4W 8 <br /> 1 ElApt/Condo t <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 Apt/Condo -1 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. lXl New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> ystem 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 /> No....n--,,,P,,,((((re��_�ssurized Distribution Pressurized Distribution Experimental Other <br /> 11 eepage Bed 21 El 30 El SpecifyType 41 ❑ Holding Tank <br /> 1 ❑ 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 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> RE 4 IRED(sq.ft.) PROPOSED(sq.ft.) (G s�/day/sq.ft.) (Min./inch) ELEVATION <br /> Sod k� 'Z_ 6 Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New i s Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank <br /> Lift Pum Tank/Siphon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Pri ): Plu bar's signature:( OS mps) MP/MP SW No.: Business Phone Number: <br /> p <br /> lumber a Address treat, ity,State,Zip gW 1 <br /> oUN IDEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee lis rcnesg Groundwater Date u Issuing A e Sign ure( Slam s <br /> Approved ❑ Owner Given Initial Ali' /O� O� <br /> A v n �t l <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />