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FILHRDSANITARY PERMIT APPLICATION COUNTY <br /> _ In accord with ILHR 83.05,Wis.Adm.Code Ru rn <br /> _._ STATE�NITARY RMIT#al /.f <br /> —Attach complete plans(to he county copy only)for the system,on paper not less than ❑ / -7X3.7) c^f <br /> 814 X 11 IDCh83 In size. eck if revisipKtto previous application <br /> —See reverse side for Instr Actions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMAT N-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> ''/a , <br /> '/a j V <br /> E(or W <br /> ZlEgKPROPERTY O ER'S M ILING DDRESS ANE <br /> LOT# BLOCK# <br /> gEq 1'�CIN,STATEZIP CODE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 0 k <br /> Lj CITY a NEAREST R AD <br /> 11. TYPE OF BUILDING: (c heck one) ❑State OwnedVILLAGE 5 o OQN K- (�D <br /> ❑ Public ❑1 or Fam.Dwelling-#of bedrooms� Nu <br /> III. BUILDING USE: (If bui ling type is public,check all that apply) <br /> 1 ❑ Apt/Condo 'j LJ lA <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. ❑ New 2. esUReplacement 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: (Clack only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11Seepage Bed 21 ❑ Mound 30 EJ SpecifyType 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 SYSTEI A INFORMATION: <br /> 1.GALLONS PER DAY 2. BSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERI.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> R IRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Mi�n�./inch) /) ELEVATION <br /> W 2 `4 tp• Feet .L Feet <br /> 113) W.VII. TANK CAPACITY Site <br /> in 11 ns Total #of Prefab. Fiber- Expp. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name strutted <br /> Concrete Con- Steel glass Plastic App <br /> Tanks Tanks <br /> Septic Tank or Holdina Tank <br /> tom <br /> 1 771— <br /> Lift Pump Tank/Si hon Chambe 5� <br /> VIII. RESPONSIBILITY S1 ATEMENT <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:(N tamps) MP/MPRSW No.: Business Phone Number: <br /> (ct1 5 ;,,,� i4 3y ZA. 5 $66- cj <br /> P umber's Address S rest,City State,Zip Code): <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> ❑ <br /> Disapproved Sanitary Permit Fee(Includes Groundwater e e sous Is in Agent Sig t e(No Stamps) <br /> ' Surcharge Fee) f7 <br /> Approved ❑ Owner GI an Initial rT/'P <br /> Adverse termi I n ° <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> S1313-6393(formerly Plb-67)(R.1 /68) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />