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rZQE&�R SANITARY PERMIT APPLICATION COUNTYIn accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITA Y PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ I i`�� O� <br /> 8'%x11inches insize. Ch�ifrevisiont reviousaDPlicetion <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 /> r N /' A& '/4 p '/4, S TJX/, N, R / or)�O <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# ,/p BLOCK# <br /> oc <br /> DAm kAb /y <br /> CIN,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 'S OoNF - o l s ES-,;17 7 NA <br /> If. TYPE OF BUILDING: ( eek one) CITY /"a C/ NEAREST ROAD <br /> rLtJ�/ ❑State Owned VI LACE yC !C <br /> ❑ Public for 2 Fam. Dwelling-#of bedrooms A AxN BER ) <br /> III. BUILDING USE: (If building type is public,check all that apply) �_�)3�- _� _� Q G <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 l �� <br /> - l�only one in line A. Check line B if applicable) <br /> c7 <br /> A) 1. ❑ New 2. L�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 ❑ 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 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> 1—� REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Mi /inch) p ELEVATION <br /> v /.d o 7 � /�� Feet Ci Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- p . <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete A <br /> Con- Steel glass Plastic App. <br /> strutted <br /> Tanks Tanks <br /> Be tic Tank or Holding Tank /AOL 1 <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 Sta ) MPRSW No.: Business Phone Number: <br /> CEc/rl s % <br /> Plumber's Address(Street,City, tete,Zi Code): <br /> /IrT c /` <br /> IX. LINTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e Shue Issuing Agen igna ure(No a ps) <br /> Approved ❑ Owner Given Initial � c� Surcharge Fee) <br /> Adverse Determination- <br /> CONDITIONS <br /> t rmina i n V <br /> CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBO-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />