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.7—la!LHRIs SANITARY PERMIT APPLICATION couNTv <br /> E� <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITARY PE MIT# `7o rra <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than 11 �,I� I Or <br /> 8%x 11 inches In size. kif avis on revlous application <br /> –See reverse side for instructions for completing this application. STATE PLAN I.D.NUFABER <br /> I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> ,IqWR90UAI CIN 'Yt C_ '%,S T N, R E (or)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 9330 - - <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> R (✓/. 30 <br /> 11. TYPE 0 BUILDING: (Check one) State Owned El CITY VILLAGE ) NEAREST ROAD <br /> � <br /> El Public X(1 or 2 Fam.Dwelling,#of bedrooms 3PARCEL TAX N <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo <br /> 2 ElAssembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranttBar/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. TY�pPP`J�El OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. bNew 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 KSeepage 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 12.ABSORP.AREA 13.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> II '��rnrn REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Q ELEVATION <br /> 'Tjfy 13Feet -0 Feet <br /> VII. TANK CAPACITY Site <br /> in kilons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New is8n Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank <br /> Litt Pump Tank/Siphon 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 S ps) MP/MPRSW No.: Business Phone Number: <br /> IG /f1.$ OVJL" <br /> P umber's Address(Street,City,State,ZIP Codey. <br /> S4813 <br /> IX. COUNTY/DEPARTMENT SE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing A en ignat re( o tamps) <br /> pproved ❑ Owner Given Initial � _ Surcharge reel <br /> Adverse //Determination Imo`--'a W <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />