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_757DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUN <br /> STATES NITARY KRMIT#hnri 1r)n <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than '�� o o /of /V <br /> 8'%x11inches insize. ❑ ch Ifrevisiu 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 rt <br /> -swayW '/a� 'h, S Z� T N, R 1 E(or <br /> 4 <br /> P OPERTY OWNER'S MAILING ADDRESS LOT# BLOCK III <br /> CITY,STATE ZIP CODE PH NE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 1015 T5& <br /> 11. TYPE OF BUILDING: (Check one) ❑State Owned El viLUGE NEAREST ROAD <br /> N o0I R f1r- <br /> ❑ Public X1 or 2 Fam. Dwelling-#of bedrooms <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 El Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranttBar/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. ❑ New 2. 0,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 /> 11Seepage Bed 21 ElMound 30 ElSpecify 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 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> RE UIRED(sq.ft.) PR SED(sq1 412 .ft.) (Gals/day/sq.ft.) (Mindinch) a Q ELEVATION <br /> . 6L ..-5 1 4.O Feet _3 Feet <br /> VII. TANK CAPACITYin gallons Total Site <br /> INFORMATION #of Prefab. Fiber- Exper. <br /> New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank <br /> Litt Pump Tank/Siphon Chamber -� <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): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> -KCRARO kwit4s I iuj I 3g2GIt <br /> r5 )&(,- II's 7 <br /> Plumber's Address(Street,City,State,Zip Code <br /> o5 tnlEBs uJ . S`I8�i3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issui g e igna re No Stamps) <br /> Approved ❑ Owner Given Initialsurcharge Fee) <br /> Adverse Determination <br /> X. CONDITIONS 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 />