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SANITARY PERMIT APPLICATION ( <br /> 7UIL.HR In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STATE KA3�) RMIT#���(_ <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ( I'� <br /> 8'%x 11 inches in size. ❑ Check 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 /> PRQPERTY OWNER PROPERTY LOCATION <br /> Y4 ''/4, S .3T410, N, R/ E(or <br /> PROPEW OWNER'S MAI G ADDFF LOT# # �� <br /> CITY STA E ZIP C DE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER v <br /> Id 16r, <br /> It. TYPE OF BUILDING: (Check one 5 CITY NEARE R AD /ry/ - <br /> State Owned VILLAGE V=17 l Zit <br /> ❑ Public Dd1or2Fam. Dwelling-#ofbedrooms� AXNu ) cxrt.c <br /> Ill. BUILDING USE: (If building type is public,check all that apply) �� e <br /> / a.?5 —op <br /> 1 EJApt/Condo T6� <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. El 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 IAJ Seepage Bed 21 ❑ Mound 30 El SpecifyType 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 /> Vt. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REOUIR D(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 2 LEV(ATTION <br /> 3w /O Feet ��6 Feet <br /> VII. TANK CAPACITY Site <br /> in allons TotalLTanks <br /> Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallonanufacturer's Name oncrete Con- Steel glass PlasticAppTanks Tanksbj1'ejCr� struttedSe tic Tank or Holdin Tank Lia Pum Tank/Si hon Chamber ...I�� m� <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature: Ste ps MP/MPRSWNo.: Business Phone Number <br /> lumbo 's Address(Street,City,State,Zip Code): <br /> �e�, <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved [Sj�ain_ltary Permit Fee(ISurchaperouunn)water a e ssue iss g gentSignat a NoStamps) <br /> Approved ❑ Owner Given Initial I�S•VV <br /> Fee <br /> Adverse D rmin tion U <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> , <br /> SBD-6398(formerly Plb-67)(R.11/99) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />