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SANITARY PERMIT APPLICATION <br /> � <br /> DILMR In accord with ILHR 83.05,Wis.Adm.Code couNTv <br /> — r <br /> p��• �• STATE SANITARY Pq IT /q5Z <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than C7033 <br /> 8'%x 11 inches in size. 11 Check If revlslo 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 t, <br /> 0 3R ISTOL N e ''/aN '%, S Z.$ T -1,(„ N, R E(0 <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> p Co - R0- <br /> CIN,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 11. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> state owned VILLAGE, ACKSO (10 . 1Z0. 14 <br /> ❑ Public A or 2 Fam. Dwelling-#of bedrooms a— PA EL Ax U ( ) <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 ❑ RestaurantlBar/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.X 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_XSeepage Bed 21 ❑ Mound 30 ❑ Specify 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 16. SYSTEM ELEV. 7. FINAL GRADE <br /> L� D REQUIRED(sq.ttC.),� PROPOSED(sq.tt.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> (`�V 10so OS G , Z ( ��.� Feet d © Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New inti Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank C 45le <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 Signature:(No S mps) MP/MPRSW No.: Business Phone Number: <br /> F/SHA D 0 i Zb <br /> in qIS7 <br /> lumber's Address(street,city,State,Zip Cod ): <br /> Z'l -7 6 p Hj a 15S WEB TERW 54'9`13 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee includes Groundwater ate IssuedIssuing A n ignat re( o mps) <br /> ,y, Surcharge Fee) <br /> Approved ❑ Owner Given Initial "qt{t, I5Se CXSD 6_I I _ <br /> Adverse Determination V�� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />