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SANITARY PERMIT APPLICATION <br /> �� In accord with ILHR 83.05,Wis.Adm.Code cou TY <br /> STA SANIT YPERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than 9.4,1 ) )P F�o <br /> 8'h x 11 Inches In size. heck 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 /> (gyp S(15ILlq '/4 a, S 13 T N, E (or W <br /> PROjERITY OWNER'S M�IL$INGC^DrDRESS LOT#(RC1 BLOC # <br /> CITY,STATE N J •JZIP OODE PHONE NUMBER r <br /> u W1 . 5422 L; )314-300 El CITY A <br /> c <br /> It. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE NE RST ROAD�7 <br /> M1 <br /> lA/I S5 1 <br /> ❑ Public M 1 or 2 Fam. Dwelling,#of bedrooms Z PARCEL TAX NUMBERS) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) o3a-��13 _ 0 <br /> S� <br /> 1 ElApt/Condo ll \ ✓ <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. ❑ 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 M 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 PERDAY 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) IS-1 <br /> 300 42-9 32 .7 �' Z Feet / D•1 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Hold in Tank �' <br /> Litt Pum Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached p ans. <br /> Plumber's Name(Print): Plumber's Signature:(No mps) MP/MPRSW No.: Business Phone Number: <br /> c o inl5 � z� 5 /57 <br /> Plumber's Address(Street,City,State,Zip Code). <br /> 1-73bo OW s Wk;65%9 W- 5y8 3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date IssuedIssuing g tsi iatu IN S ps) <br /> ,-I Suro�hacge Fee) <br /> IM Approved ❑ Owner Given Initial �.`(]� <br /> 77TT ` Adverse Determination J L% 1 1 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SB66398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Ow er,Plumber <br />