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SANITARY PERMIT APPLICATION COUNTY <br /> MLHR In accord with ILHR 83.05,Wis.Adm.Code bu rnf <br /> STATE SANITA PERMIT# �- <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than j5 3) <br /> 8%x 11 inches lnsize. ❑ Checkitrevi onto 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. 2 I I <br /> PROPERTY OWNER <br /> G u r PROPE/TYLr- TION <br /> Ila,S T 3k, N, R E (or W <br /> PR PERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> -'27loz. <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> II. TYPE OF BUILDING: (Check one) CI NEAREST ROAD <br /> ❑ State Owned VILLAGE <br /> ❑ Public 5&1 or 2 Fam.Dwelling–#of bedrooms L (b) 1� <br /> Ill. BUILDING USE: (If building type is public,check all that apply) C.' <br /> 1 ❑ Apt/Condo <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.X 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 /> 1ASeepage Bed 21 El 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.ABSORR AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) Min./inch) n r' ELEVATION <br /> 3 C)Q Lfl3� a lP� -1 1 • p Feet 102,S Feet <br /> VII. TANK CAPACISite <br /> in allTotal #of Prefab. Fiber- <br /> OZ Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank O — I -ISO <br /> Lift Pump Tank/Siphon Chamber <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's Signature:(No Stamps) 1MPJMPIRSvl Business Phone Number: <br /> R/814RRO &PWl 3`126 rS (o(, is <br /> Plumber's Address(Street,City,State,Zip Cod ): <br /> o w� �S IvC95rt)2 Syg�i3 <br /> IX. COUNTY/DEPART ENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date IssuedIss n Agent Slgn tura(No Stamps) <br /> r /_;�Surcharge Fee) _ <br /> 11 <br /> pproved ❑ Owner Given Initial 10770 0 _ �_C� <br /> Adverse rmin tin �H <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: 67 1 <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 6 Buildings Division,Owner,Plumper <br />