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SANITARY PERMIT APPLICATION &`�`- <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTY <br /> c/9 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE SANITARY PERMIT <br /> SAB 7��g <br /> 8%x 11 inches in size. ❑ Check if revision to 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 <br /> SO-)Y4 dltt)'/4, S Iq T `f i), N, R Irl' E;u#W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> eIO O �?+a; rt.U. ii <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NU ER <br /> 1 1. C V/ <br /> II. PE OF BUILDING: (Check one) ❑ State Owned 0 VILLAGE SCO NEAR1ROAD <br /> ❑ Public 91 or 2 Fam. Dwelling—#of bedrooms3 PARC LTAX NUMBER(S) <br /> R( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) rG *L <br /> 1 ElApt/Condo M4,�/ <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 31`010 ❑ 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. ❑ 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 ® Seepage 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 /> 1/ REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 4sc> 10+3 1,049 • -7 . 1 q4.9 Feet glo.rt Feet <br /> VII. TANK CAPACITY Site <br /> in gallons TotalLTanks <br /> Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New istin Gallons Concrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank o OOp pep <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of th onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): M & K Plu er' ignature:( o Stamps) IIMMPRSW No.: Business Phone Number: <br /> SEPTIC & EXCAVA ION <br /> Plumber's Address1 �f�g): <br /> Spooner, <br /> IX. COUNTY/DEPA T NT US NLY <br /> ❑ Disapproved Sanitary Permi Fee(Includes Groundwater ate ssue Issuing Age Sign ure( ps) <br /> Surcharge Fee) <br /> pproved ❑ Adverse veermial " <br /> Adverse Determination <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 />