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MMMMI <br /> R SANITARY PERMIT APPLICATION COUNTY <br /> 7DILH__ In accord with ILHR 83.05,Wis.Adm.Code <br /> �~ �w STATEPANITA PERMIT#I-1��$n <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than /,��� I I f <br /> 8'/z x 11 Inches In size. ❑ eck if revi on 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 QWNER PROPERTY LOCATION <br /> Kms!) ne r�Y. v4, S /� T�f , N, R 14 �T W <br /> PROPERTY OW ER'S MAILING ADDRESS LOT# v� ' BLOCK# <br /> S "sem Lx ,[�i1. • `� <br /> CIN,STATE CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 010 <br /> CITU I NEAREST ROAD !A <br /> it. TYPE OF UILDING: (Check one) ❑ State Owned l7 VILLAGE �/ ✓r �55 4/T. <br /> ❑ Public 91 or 2 Fam.Dwelling-#of bedrooms_& I ARCELTAX <br /> ,NU/M R( <br /> 111. BUILDING USE: (If building type is public,check all that apply) aU —311 I^ O q'- )r <br /> 1 ❑ Apt/Condo I <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 R Seepage Bed 21 ❑ Mound 30 ❑ Specity 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 13.ABSORP.AREA 14. LOADING RATE 5. PERI.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 450 �00 <3 9416i Feet 91:•o Feet <br /> VII. TANK CAPACITY Site <br /> n lions Total #of Prefab. Fiber- Exp <br /> I . <br /> INFORMATION New datingGallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App. <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holdino Tank 1000 /000 1 <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of th ite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plu er's Signat re: Stamps) MPRSW No.: Business Phone Number: <br /> u. S�1 3353 7i� 638=7�8z. <br /> Plumbe ' Address(StreeIty,State,zip Code): <br /> 5r AX 77*d =k&_2Z <br /> fir_ go/ <br /> IX4 COUNTY/DEPARTMENT USE NLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e Issued 1 Issuing AT!qt net r 10 Sia <br /> roharge Fee) /} <br /> " ApprovedSu <br /> ❑ Owner Given Initial 1l1T /t'!-1 <br /> Adv D rmin n ��JJ''.•''.,JJ Vl� <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-5398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />