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Z77Q��HR SANITARY PERMIT APPLICATION <br /> v <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTY <br /> STATE.SANITARY PERMIT# B5_5� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ( ( ` <br /> 8'%x 11 inches in size. ElCheck if revision to 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 PROPERTY LOCATION <br /> /I ,tom 4&LI ee, /l.'t i:'ti/aS�'/a, S 3 S T2�f, N, R <br /> PROPER OWNER'rS M�IL�G ADDRESS� LOT# BLOCK# <br /> /U H-& ` . <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> El CITY <br /> II. TYPE OF BUILDING: (Check one) ❑State Owned VIL AGE 'TOWN QF� ' NEARE T RO D -70 <br /> ❑ Public 1 or 2 Fam. Dwelling-##of bedrooms PARCEL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo 1 v <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. X 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 DAY 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> RE/Q/UIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) t�(Miin/./inch) r -7 _ ELEVATION <br /> �`Cl 7 C � / 7 ! /� S Feet ? ! Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App. <br /> Tanks Tanks strutted <br /> Septic Tank' r Holding Tank - <br /> �c <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 Nam (P 'nt): Plu ber's nature (N tamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(S eet,City State,Zip Co9p): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater ate Issued ss mg gent Sign a(No Stamps) <br /> Approved ❑ Owner Given Initial Surcharge Fee) <br /> Adverse Determination �, t- <br /> CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> e,- <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />