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SANITARY PERMIT APPLICATION <br /> IR In accord with ILHR 83.05,Wis.Adm.Code couNTV nett <br /> — Bur <br /> .w.,.,.,er..,.,.a STATE SANITARY PERMIT <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than O-7 <br /> [] C51la� <br /> 8'%x 11 inches in size. heck if revislon 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 /> FEA N< F R U C - '/s Ne ''/a, S T I , N, R I5 E(o W <br /> PROqRYY OWNER'S MAILING ADDRESS LOT#/; BLOCK# <br /> (�i�Y t. c.�� <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> IL TYPE OF BUILDING: (Check one) CIN : NEAREST ROAD <br /> ❑$tate DWned VILLAGE: r.\�cC F19 VJ 1 i lam- Ro— <br /> ❑ Public ®tor2Fam. Dwellings of bed rooms Z_ RF <br /> L Nu BFR(1J I WI 7-1\ !\ <br /> III. BUILDING USE: (If building type is public,check all that apply) :3;?1 3 8/� <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 L1 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. V\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 /> 1116 Seepage Bed 21 El Mound 30 ❑ Specify Type 41 El Holding Tank <br /> 12Seepage 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 2SORP.AREA 13.ABSORP.AREA 4. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ff.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Ml /inch) c� ELEVATION <br /> Soo I 'W6 . �'d I - l Feet _ Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic App.INFORMATION New ank Gallons Tanks oncrete structed glass App'p. <br /> Tanks Tanks <br /> Septic Tank or Holdino 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:(No Stamps) MP/MPRSWNo.: Business Phone Number: <br /> Ict114RD I�oPK/NS N CS U` qt�? <br /> Plumber's Address(Street,City,State,Zip Code <br /> 2_ 11(oo kww 35' W>rg5TER WI . 54295 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Lj Disapproved Sanitary Permit Fee(Includes Groundwater a e aeu I in Agent Si lure(No Stamps) <br /> C Surcharge Fee) <br /> Approved ❑ Owner a Deter" <br /> en Initial 13s l oz:) 31 /a <br /> Adverse t rminati n �J "! <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />