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SANITARY PERMIT APPLICATION COUNTY <br /> 70ILHR In accord with ILHR 83.05,Wis.Adm. Code <br /> STATES ITARYPTMIT#lA <br /> -Attach complete plans(to the county copy only)for the system,on paper not less thani�l�.� ; f <br /> 8%x11 inches In size. ❑ Check if revision 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 <br /> VIOLA , o1/4 /s,S T � , N, R JE (or W <br /> PROPERTY OWNER'SMAILING DRESS LOT#0 <br /> BLOCK# <br /> V - r P111 <br /> CITY,STATE I ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> W1 <br /> II. TYPE O UILDING: (Check one) CITY NEAREST ROAD <br /> �yI El Owned VILLAGE S W ) < r 71 <br /> ❑ Public 91 or 2 Fam. Dwelling-#of bedrooms— LTAxNu ERIS) <br /> 111. BUILDING USE: (If building type is public,check all that apply) <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. XlReplacement 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 /> 11Seepage Bed 21 ElMound 30 ❑ Specify Type 41 El HoldingTank <br /> 12 5 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 PER71 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./ h) <br /> 2 ELEVATION <br /> 3o� 0 .3 Feet 3 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glace Plastic App <br /> Tanks Tanks strutted <br /> TM r <br /> Septic Tank or Holdin Tank <br /> Litt 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' Signature: Nos pa) MP/MPRSW No.: Business Phone Number: <br /> It f r�5 66 - :5 <br /> lumber's Addresse (Street,City,State,Zip Code: <br /> k)I 5 13 <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> Disapproved sanitary Permit Fee(Includes Groundwater Date IssuedIssui ent Signatur tamps) <br /> e,µµµ Surcharge Fee) <br /> Approved ❑ Owner Given Initial /'"S. � _ c <br /> Adv Determination ` / r / <br /> Of 61, <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 />