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77— SANITARY PERMIT APPLICATION <br /> DILHR In accord with ILHR 83.05,Wis.Adm.Code COUNTY D <br /> STAT ESANITARy\PERMIT#1c)'13rJ.3 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ ;fie <br /> cf <br /> 8'%x 11 inches in size. eck if rev f 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 OWNER PROPERLf�t <br /> ON <br /> E PERI K Z1W YS 5� T3 , N, R (, E (orPROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> f I NIACITY,STATE ZIP CODE PHONE NUMBER SUBDrIIVVIOR CSC NUMBER-cif S ��ls L / <br /> If. TYPE OF BUILDING: (Check one) CITY : r/PL 1NEAREESST'ROADS" <br /> ❑ State Owned �+ VILLAGE E O L PE Eli <br /> ❑ Public �1 or 2 Fam. Dwelling,#of bedrooms` R( ) <br /> 111. BUILDING USE: (If building type is public,check all that apply) I Q— <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 Bit applicable) <br /> A) 1. ❑ New 2.,KReplacement 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 /> t1 <br /> 11 El Seepage Bed 21 ❑ Mound 30 ❑ SpecityType 41_LK 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 PERDAY 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 /> 3 O 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 structed <br /> Septic Tank or Holdina Tank BOO 00 <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 mps) MP/MPRSWNo.: Business Phone Number: <br /> 14 OIL, o zjn 15 66- is <br /> Plumber's Address(Str et,City,Stat ,Zip Code): <br /> Uj,-1 l,J I '_Z�JS93 <br /> IX.,COUNTY/DEPARTMENT USE ONLY <br /> 01 Disapproved Sanitary Permit Fee(Includes Groundwater a e ssu Issugent Signa u (No Stamps) <br /> Approved ❑ Owner Given Initial _ Surcharge Fee) <br /> Adverse Determination "� ' L <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />