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`N COMPUTEMSCANNED Ir 21l'L �C� m <br /> SANITARY PERMIT APPLICATION �+°f'T '�,/�' <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY r / <br /> Burr " <br /> STATESANITARY ERN)IT# <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ��TT//,, �!//776- <br /> 8%X 11 Inches In size. Check if revision to previous application <br /> —See reverse side for Instructions for completing this application. ATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. _ <br /> PROPERTY OWNEV PROPERTY LOCATION <br /> \11O k t +Z Ot.cJ 0'/a C'/4,S 2—'1T37 N R <br /> PROPERTY OWNER'S MAILING ADDRESS ( LOT# BLOCK# <br /> CITY,STATE r ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> wt a -26� � � V 2 P r310 � <br /> If. TYPE OF ILDING: (Check one) CITY NEAREST .OAD <br /> State Owned O VILLAGE VI TOWN rtu,�6L C��4Vo/44- <br /> [] Public X 1 or 2 Fam. Dwelling–#of bedrooms AR L AX N MBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) ©34— / �., O� <br /> 1 ElApt/Condo 1 <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. El New 2. VN 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 X 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 /> V1. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> /� REOUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> [� <br /> eet Feet <br /> CAPACITY <br /> VII. TANK #of Prefab. Site Fiber- Exper. <br /> in allons Total Manufacturer's Name Con- Steel Plastic <br /> INFORMATION New istin Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank oIdin T 1EW 1 (,!.)I,eSer C <br /> LiftPum Tan I on Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility fo installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plu ber's SignaturMP/MPRSW No.: Business Phone Number: <br /> tae =;e�:, I MP <br /> �6- <br /> Plumber's Address(Street,City,$tale,Zip Code)' <br /> 7 "Le 2 " t,(/e (o ,�� �;y <br /> IX. COUNTYIDEPARTMEN USE ONLY <br /> Disapproved Sanitary Permit F@q(Includes Groundwater <br /> Issuing Ag Si <br /> Approved ❑ Owner Given Initial Surcharge Fee) <br /> Adverse Determination / re No <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />