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D���� SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis. Adm. Code '0"' <br /> ; � STATErSANITARY ERMIT#f51 j'1G� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ �C '�� � x3 X <br /> 8%X 11 Inches In size. Check if revi ' n 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 PROPERTY LOCATION <br /> 3 l ' _/- '/a '/, , TQN, R �s E (orW� ?�f 4 : <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 0/1-6 i /4-' <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 0 CITY NEAREST ROAD <br /> 11. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE:JOWN OF' <br /> A/l 4,- <br /> Public ❑ 1 or 2 Fam. Dwelling—##of bedrooms— PARCEL TAXNUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) b �b� <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 El ,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. ❑Replacement 3. El Replacement of 4. ❑ Reconnection of 5.El 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 Seepage Bed 21 ❑ 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.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> f REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day7/sq.ft.) (Min./inch) ELEVATION <br /> / ' �� fi •5 25` ���U Feet Feet <br /> VII. TANK CAPACITY Site <br /> in all on s Total ##of Prefab. Fiber- Exper. <br /> Manufacturer's Name Con- Steel Plastic <br /> INFORMATION <br /> New rxisting Gallons Tanks Concrete structed glass App. <br /> Tanks I Tanks <br /> ,, <br /> Septic Tank or Holding Tank �- y' �r� <br /> El <br /> Lift Pump Tank/Siphon Chamber I <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): Plum4see-Sk-wature:( Stamp MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date issuedIssuing Age Sign ure( o tamps) <br /> Surcharge Fee) <br /> Approved D Owner Given Initial I r,,� <br /> Adverse Determination V <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 />