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SANITARY PERMIT APPLICATION COUNTY <br /> i�'�Llr�ln In accord with ILHR 83.05,Wis. Adm. Code <br /> STATE SANITARY PERMIT#1�3y�U� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ (� � 1 <br /> 81/2 x 11 Inches In size. Check if revisio o 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 OWNED--, PROPERTY LOCATION <br /> ,>/� /// �� � � i : '/4 '/4, S . T ti_. N, R / E (oryk <br /> PROPERTY OW 'S MAILING ADDRESS . LOT## BLOCK## <br /> CITY ESTATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER / <br /> I. TYPE OF B 1LDING: (Check one CITY L ` NEAREST ROAD <br /> I <br /> El Owned _ VILLAGE:TOWN OF: <br /> Q�C' la! n _FsaL 16 <br /> ❑ Public 1 or 2 Fam. Dwelling—##of bedrooms PARCEL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) <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. 1� New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only L_ Existing System Existing System <br /> B) XA Sanitary Permit was previously issued. Permit## J � Date Issued 6 <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 [:1 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) LEVATION <br /> r <br /> i/ Feet (i Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons 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 /> Septic Tank or Holding Tank _ / U, ` ! 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 Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumbetr',5.,Address(Street, ity State Zip Code): <br /> 5 7� <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Signature(No Stamps) <br /> �Approved rSurcharge Fee)❑ Adverse Given -0, /66. �� .� <br /> Adverse Determination J �,�1,� J <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />