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SANITARY PERMIT APPLICATION COUNTY <br /> 7DILMR In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITARY PERMIT#tg'�//Lf/ 1 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than 'I/�-I(O/�TA�'jY / D`-'/—r <br /> 8%x 11 inches in size. ❑ 2ck if rev Ion 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 /> RV A E50 tJ '/a ''/a, S 25y T 40, N, R ��o E(o W <br /> PR /OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> �h c4-G <br /> I ,SJ TE ZIP F PHONEo 1 NUMBER SUBDIVISI NNAME OR CSM NUMBER <br /> II l CIN NEAREST ROAD <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE O 9 <br /> ❑ Public 41 or 2 Fam. Dwelliriof bedrooms A LTAx e <br /> 0�1o�-©�f- 7oD <br /> III. BUILDING USE: (If building type is public,check all that apply) �ko <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: (Check only one in line A. Check line B if applicable) <br /> A) 1llew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> ASystem 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 /> 1ASee❑ <br /> page Bed 21 ElMound 30 EJSpecify Type 41 ❑ Holding Tank <br /> 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 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Q / ELEVATION <br /> 7-0 Z,Q ,�p z,,, 3 1 '14 Feet Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION Manufacturer's Name Con- Steel Plastic <br /> New istin Gallons Tanks oncrete structed glass App. <br /> Tanks Tanks <br /> Septic Tank or Holdina Tank 1000 <br /> Litt Purnip Tank/Si hon Chamber F1 F1 F1 <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): Plumb 's Signature:(N tamps) MP/MPRSW No.: Business Phone Number: <br /> __, <br /> A o� 7L is g66 IS <br /> um is Address(St eet,Ciry,Sta e,Zip Cod : U <br /> 21 w v 35f - <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee uncludea Groundwater ae ssue IasuingA ent inn No <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial <br /> Adverse Determination TT <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />