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ori writ <br /> SANITARY PERMIT APPLICATION cou117L <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STA II)TAR' <br /> PE_R�` # <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than � <br /> 8'%x 1.1 inches in size. heck i revlslon to previous application <br /> —See reverse side for instructions for completing this application. STAI E PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> /rrt L-✓e Z c_/^ '/4 '/a,S T 3j, N, 13 16 E (o <br /> PROPERTY OWNER'S MAILING ADDRESS_ LOT LOC # <br /> Tr,f, / 1 6L I j <br /> CITY,STA7E ZIPCODE I PHONE NUMBER SUBDIVISION NAME OR GS4 NUM E <br /> El It. TYPE OF BUILDIl IIN�NG: (Check one) ❑State Owned VILLAGE A- ST�RO/}D� n <br /> ❑ Public L41 or 2 Fam.Dwelling—#of bedrooms PAR EL IAXNUMBER(S) � ROC <br /> U <br /> 111. BUILDING USE: (If building type is public,check all that apply) _0 f1� <br /> 1 ❑ Apt/Condo w �V <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Res urant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 E] Sery ice 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 Bit applicable) <br /> A) 1. [A 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 El SpecityType 41 El 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 F1 2.ABSORP,AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. YSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> �� Feet r1�. / Feet <br /> CAPACITY <br /> VII. TANK Site <br /> In- <br /> INFORMATION <br /> allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons of Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or 000 /Oct' <br /> Lift Pump Tank/449ionjChamber 600 660 F1 F-1 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached pi ans. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) 44VMPRSW No.: Business Phone Number: <br /> Plumbs ''' Address(Street,City,State,Zip Code): t <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Inncludeee�e gGqroundwater F <br /> e ssue Issuing g Si ature N t s) <br /> Approved ❑ Owner Given Initial 'I .u�L ss) l(Adverse Det rmination n —I 1 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD66398(R.(W/93) DISTRIBUTION: Original to County,One Copy To:Safety B Buildings Division,Own r,Plumber <br />