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Mil. HR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code D 1JE 9a-04f jf <br /> �"....."'�., I <br /> ' STA�3ANITARY PERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than 17q ate <br /> 3(Q <br /> 834 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 /> DEF-RAf�,EL O i G.u'J 0,o o 5-(.4..) 1/4 PU)%,S /to T 7,N,R !... -E(fit <br /> PROPERTY OWNER'S MAIUNG ADDRESS LOT# BLOCK# <br /> C/O G-i•JE BQODU Z B L3.E S • � <br /> CITY,STATE ) ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> ofsEggiao,i,tii 63s3/ (6o8' )16't-43cb <br /> II. TYPE • BUILDING: (Check one) ❑State Owned viu_A�GpEp:p NEAREST ROAD <br /> �1 RCEI.T/I7(NUNe�P I aQ $ GV/� 12dY49 <br /> ►._ blic <br /> 11I. BUILDING USE: (If building type is public,check all that apply) (Z — 0 7 1 Z -) o _ e(�Z.p <br /> 1 El Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 Outdoor Recreational Facility <br /> 3 El Campground 7 ❑ Merchandise: Sales/Repairs 11 R wmrte/Diwieg <br /> 4 El Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 El Other: Specify. <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1.❑ New 2.0 Replacement 3. El 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 /> 04 I/G S/ <br /> Non-Pressurized Distribution Pressurized Distribution Experimental • t.-r #..p a't <br /> 11 Seepage Bed 21 El Mound 30 ❑ Specify Type _Kr oldiffk <br /> 12 eepage Trench 22 ❑ In-Ground 42 C• �jrrivy <br /> 13 Seepage Pit Pressure 43 ■ ' ..t4Privy • <br /> 14 ❑ System-In-Fill O� <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 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) 77.GI 7f.e/ EV ION <br /> 6 M t 3.61 2.. /305 o.s /1,4 8a.0/ Feet 3 o7_ cee <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Manufacturer's Name Prefab. Fiber_ Plastic Ever. <br /> Con- Steel <br /> INFORMATION New Existing Gallons Tanks Concrete glass App. <br /> Tanks Tanks �f structed <br /> Septic Tanktf lk --- 2(X ' �O N9S' ` e n U <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): Plum Signature:( Stam MP/MPRSW No.: Business Phone Number: �/ <br /> L�r„Cvo itl•t- .4-111 I If')I7 l (0 )g7/J6oK F� <br /> Plumber's Address(S ,City,State,ZI ): . .+ <br /> IX. COUNT Y/D0EPARTMENT USE ONLY <br /> t 1 w W fs �j l Q9 <br /> [] Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued IssuinZi <br /> ent Signature(No Stamps) <br /> @Approved El Owner Given initial Surcharge Fe.) <br /> Adverse Determination i i G1?-6 if' __ Aq /k41.45 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL <br /> ALL— WORK MUST BE compLeTeb AY LlC&Seb Pli,1►B6e. <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />