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ffDROILHR SANITARY PERMIT APPLICATION COUTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITAR RMIT <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ (11,-17(o OPV O <br /> 8%x 11 inches in size. Check If revisl o previous application <br /> -See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPER OWNER PROPERTY LOCATION //� ll <br /> VVI ld ''/4jt '/4,Sp7 T39, N, R E(or)(� ) <br /> PROP TY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> O <br /> CITY STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> eIJ <br /> 11. TYPE OF BUILDING: (Check one) LJv LTMtAGE State Owned : eA/v NEA` � �D <br /> ❑ Public �1 or 2 Fam.Dwelling-#of bedrooms ) <br /> 111. BUILDING USE: (If building type is public,check all that apply) © ! 4 3 —7 DS--300 S-_ 7a Q <br /> 1 ❑ Apt/Condo !J l J <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"RR 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 LLLJJJ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. ew 2. El Replacement 3. El 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 I Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 �J Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 El 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.) PROPOSE,Q(sq.ft.) (Gals/day/sq.ft.) (Min./inch) q ELEVATION <br /> Q 'U , (� 'Z,r ! Sr Feet Feet <br /> VII. TANK CAPACITY Site <br /> in 11 ns Total #of Prefab. Fiber- p . <br /> INFORMATION New Istin Gallons Tanks Manufacturer's Name Concrete A <br /> Con- Steel glass Plastic Apppstrutted <br /> Tanks Tanks <br /> Se tic <br /> Tan or Holdin Tank <br /> i um 7ank/Si hon Chamber 11 1 Li <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): PI bar's Signature:(No to ps) MP/MPRSW No.: Business Phone Number: <br /> � <br /> IumDer's ddress(Street,Cly,State,Zip Code): <br /> v �FrJr 3604 <br /> IXj COUNTYIDE ARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Ineludes hargea Fee star a e esus Is g Agent i ature(No Stamps) <br /> surcFee) <br /> Approved ❑ Owner Given Initial r-7 f3 161" YZLd;o� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />