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SANITARY PERMIT APPLICATION <br /> 7DILHR In accord with ILHR 83.05,Wis.Adm.Code c uNTY <br /> • W STATE SANITARY PERMff# l�?,-jCZI <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than \61 <br /> 8'%x 11 inches in size. ❑ Check if revision to prev us 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 O R PROPERTY LOCATION <br /> .nw , I rbc A/9%PF, %, S 3s-IBLWf <br /> , N, R / E (or)W <br /> WO Ty MAILING. ADDRESS LOT# <br /> O / Y <br /> TY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBP <br /> 0 4ICS <br /> It. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned VILLAGE s f S S p P�VC9 a <br /> ❑ Public 1 or 2 Fam. Dwellings of bedrooms AXNUM -✓ <br /> III. BUILDING USE: (If building type is public,check all that apply) C -���-G `Q cd <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 ❑ RestauranUBar/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.S 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 N Seepage Bed 21 El Mound 30 ❑ Specify Type 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 /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 12.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PER'.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) � ELEVATION <br /> G Z Y t0 �3 Z- - (0 S � � . Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank - 0 tl 'V 1✓.1' C <br /> Lift Pump Tank/Siphon Chamber <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 Stamps) MP/MPRSW No.: Business Phone Number: <br /> p <br /> �l od�rrc k A0,4141 19 9 W,-YI 7 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> * t1 fir— w` <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater e e ssue I uin Agent Sig t e(No Stamps) <br /> Approved ❑ Owner Given Initial \�CJ`(� <br /> Surcharge Feel q <br /> Adverse t <br /> CONDITIONS OF APPROVAL/REASONS 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 />