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�-► ���- <br /> SANITARY PERMIT APPLICATION <br /> v'iLH' In accord with ILHR 83.05,Wis.Adm.Code COUNTY �W <br /> STATE SANITARY PERWT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than <br /> ❑ <br /> 8'%x 11 inches in size. Check if rlvision 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. �" Q <br /> PROPERTY OWNER IPROPERTY LOCATION <br /> S4 '/4XV1/4,S j V TJ N, R E(or <br /> PROPERTY OWNER'S MAILING ADDRESS t/ LOT# BLOCK <br /> / 2- R — 70 ,y <br /> td .5 . No / <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Gro f S Id //�bl <br /> II. TYPE OF BUILDING: Check one) Li CITY NEAREST ROAD <br /> f� ( ❑ State Owned r� VILLAGE:�e Ij� A id o <br /> ❑ Public �1 or 2 Fam. Dwelling—#�of bedrooms L PAR EL TAX NUMB R(S) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ ApVCondo w� <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ElOutdoor 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. ❑ 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 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) �/ ELEVATION <br /> 6TJ (� s6d SU o A � * /3' 7 Feet S, i Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank too 5 lzlo0 <br /> Lift Pump Tank/Siphon Chamber 8001 q d D cv <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 Sta s) MP/MPRSW No.: -Business Phone Number: <br /> r� �� t� <br /> Plumber's Ad ress(Street,City,State,Zip Code) <br /> X <br /> IX..COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(includes Groundwater I Date Issued Issui gent Signature(No Stamps) <br /> �'y-� <br /> pproved Q Owner Given Initial <br /> erse Surcharge Fee) <br /> -co <br /> AdvDetermination zow <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />