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SANITARY PERMIT APPLICATION <br /> E bIL.HR-1 <br /> In accord with ILHR 83.05,Wis. Adm. Code COUNTY �f <br /> STATE SANITARY PE M IT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than �� /� T <br /> 8%x 11 inches in size. ❑ Check if revision t 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. si <br /> P PERTY OWNER PROPERTY LOCATION <br /> G r l` _ u — /a ,E `'/a, S iz , N, R E <br /> PROPERTY OWNER'S MAILING ADDR,W LOT# BLOCK# <br /> O M le <br /> ITY,ST TE ZIP CODE PHONE NUMBER SUBDIVISIO NAME OR CSM NUMBER <br /> � <br /> LT <br /> D`tS � <br /> o <br /> II. TYPE BUILDING: (Check one 71 CITY /_ � NE EST ROAD <br /> State Owned ❑ VILLAGE �5L TOWN OF: f�'/(�- S1 4).."( <br /> ❑ Public �9 or 2 Fam. Dwelling—#of bedrooms� ' ARCELTAXNUMBERO <br /> III. BUILDING USE: (If building type is public,check all that apply) '3 <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. 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 DI-lolding 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 /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 3 C G - __ Feet Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in ga ons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App. <br /> Tanks Tanks structed <br /> Se tic Tank or Holding Tank Lf I <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 ignature:(No Stamps MP/MPRSW No.: Business Phone Number: <br /> r c•� OJ/ )� .� <br /> Plumbs s Address(Street,City,State,Zip Code). <br /> IX. OUNTY/D PARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee (In6ludes Groundwater Date IssuedIssuing en ign ure o tamps) <br /> Surcharge Fee) - <br /> Approved ❑ Owner Given Initial l CD <br /> i I_ <br /> Adverse Determination i ' <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 />