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SANITARY PERMIT APPLICATION ooubgY <br /> 70ILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> _ --- .t5tarn f <br /> STATE SANITARY PERMIT <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ ��// l <br /> 8%X 11 IDChe3 In size. Check I r(vision 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 /> Rwr-t MqI. /Nt2 S '% Ax4i a, S (3 T 3 , N, R y*(Or) <br /> PROPERTY OWNER'S MAILING ADDRESS / LOT# BLOCK# <br /> S/y Lem 1l Rd <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR M NUMBER <br /> Po < e / U'r rd toxo r TrarG <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD /� <br /> ❑ State Owned O VILLAGE: �7 N�k n! 4;ry . /C <br /> ❑ Public ®1 or 2 Fam. Dwelling–#of bedrooms— AR EL NUMBER( <br /> III. BUILDING USE: (If building type is public,check all that apply) LI--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 B if applicable) <br /> A) 1. P 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 ❑ Specity 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 /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) q ELEVATION <br /> e Q / 0 Y_ K' ! 3 '7 Feet 9f', / Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App. <br /> Tanks Tanks strutted <br /> Septic Tank orHoldin Tank SQ MG <br /> Lift Pum Tank/Si hon 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 SSiignature:(No Stamps) MP/MPRSW No.: Business Phone Number. <br /> I.IR✓IP Q a © 7- <br /> Plumbei s Address(Street,City,State,Zip Code): <br /> Tr ` <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e Issued Issuin Agent Sign (No Stamps) <br /> Approved ❑ Owner Given Initialdl n; surcharge Fee) <br /> AdverseDetermination / � <br /> �0 V < r D <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: ' <br /> SBD-6398(formerly Plb-67)(R.11/98) DISTRIBUTION: Original to County,One Copy To:Safety 6 Buildings Division,Owner,Plumber <br />