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(� SANITARY PERMIT APPLICATION <br /> U flLHR In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> ��- STATE SANITARY RMIT#�3a, <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than SANITARY <br /> nV / <br /> 8'%x 11 inches in size. ❑ Check if revisioh 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 PERACATION <br /> t 5 /yzt '/a, S 7 T�O, N, R /y E (or <br /> PROPERTY OWNER'S MAILING ADDRESS BLOCK# <br /> # /30 �)A <br /> CITY,STATE ZIP CODE PHONE NUMBER NAME OR CSM NUMBERS K . S- S/o8 / 6</ • 7Y/ u G�tct/ �Clr{iGrl 14b � V(II. TYPEOFBUILDING: (Checkone) NEARS T ROAD /�❑StateOwned S e c �- �� 6020n <br /> Public 1 or 2 Fam. Dwelling-#of bedroomsNUMBER( ) <br /> III. BUILDINGUSE: (If building type is public,check all that apply) _ ��_ �J <br /> 1 ❑ Apt/Condo I J <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. ❑ 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 41 ❑ Holding 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 1 2.ABSORP,AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROLP/OSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 91 <br /> 0 0 ) .(e Feet Feet <br /> CAPACITY <br /> VII. TANK #of Prefab. Site Fiber- Exper. <br /> in allons Total Manufacturer's Name Con- Steel Plastic <br /> INFORMATION New istin Gallons Tanks Concreteglass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank S O ]' k4 L <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's Signature:(No Stamps) MP/MPRSWNo.: Business Phone Number: <br /> AS d-f is tiL k Ao /f ws e <br /> Plumber's Address(Street,City,State,Zip Code): <br /> W . t k-%a- v-4_, <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issu' g ent Sign (No Stamps) <br /> Approved ❑ OwnerGiven Initial surcharge Fee) <br /> DeterminationAdverse � o.1). M a-- —� <br /> k."CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)F.11/99) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />