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:1 IgerR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STATE SANITAR <br /> -Attach complete plans to the county co only)for the system,on paper not less than f <br /> P P ( tY PY Y) Y P P - j tiQ <br /> 8%x 11 inches in size. ❑ Check If revi n 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 P OP RTY LOCATION <br /> \ �`�} �(� '/a S� ''/a,S 'L T N, R E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> C� - 0 D(p A <br /> CITY,STATE { �i ZIPCODE PHONE NUMBER /���! <br /> W• S 4"/C.G../ <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned VILLAGE <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms— A LAX NUMB <br /> Ill. BUILDING USE: (If building type is public,check all that apply) 64 <br /> / -- ' •- ( p�( -w V <br /> 1 ❑ ApVCondo <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. El 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 /> 11Seepage 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 DAY 2.ASSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> RE UI ED(sq.ft.) PR POSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) G}ELEVATION <br /> 30o O .(o 3.� Feet (160.3 Feet <br /> VII. TANK CAPACITY Site <br /> INFORMATION T allons Total #of Prefab. Fiber- Exper. <br /> New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank --� <br /> Lift Pump Tank/Siphon ChamberEJ <br /> Vlll. 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'sSignature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's ddresa(Street,City,State,Zip Code): <br /> 2-1,79 H w3s Was r. 5 <br /> IX. OUNTY/DEPART ENT USE ONLY <br /> ❑ Disapproved I Sa�ry Permit Fee(Includes Groundwaterl Date IssuedIssuing AgentSi ature Stam ) <br /> Surcharge Fee <br /> pproved ❑ Owner Given Initial I P\r` y <br /> Adverse Determination <br /> r O'-� ' w <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBO-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />