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SANITARY PERMIT APPLICATION COUNTY B <br /> 7DILHFI In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE$ANITARYERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ( 15,A <br /> 8'%x 11 inches in size. ❑ check If revie' n to previous application <br /> -See reverse side for instructions for completing this application. STATEPiLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPER WNER PROPERTY LOCATION p (y <br /> Qg � L '/4 Y4, T3 N, R �J E (Oryo <br /> PRO ER O NER'S ILI G DDRELOT# BLOCK# <br /> Cip(.STAT ZIP CQQE PHONE NU UBDIVISION NAYE CSM N MBER <br /> / fX! ltl1 SLl <br /> ITY <br /> 11. TYPE OF BOLDING: (Check one) ❑ State Owned CILLAGE <br /> El <br /> 1 or 2 Fam.Dwellings of bedrooms L R( ) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) <br /> JJJ�L SGO <br /> 1 ElApt/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: (Chet my one in line A. Check line B if applicable) <br /> A) 1. ❑ New 2.X 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 21 ❑ Mound 30 ❑ Specify Type 41Holding 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 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADINGRATE 5. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> 50 REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> �� <br /> Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allona Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin 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: Ste s) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): _ (� <br /> >40 <br /> �5;4?52,5 <br /> X. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee(Includes Groundwater rffa7e issued Stamps) <br /> Determination <br /> Surcharge Fee) <br /> Approved ❑ owner Given 4 105 <br /> Adverset terrmi .00nation <br /> X. CONDITIONS OF APPROVAL/REASONS 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 />