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SANITARY PERMIT APPLICATION <br /> aDrLHR In accord with ILHR 83.05,Wis.Adm.Code COUNTY T <br /> • STATE S/�N,ITARY PERMIT Ill gq, <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ L '-7 9 oaf <br /> 8%x 11 inches in size. Check if revisi 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 OWNERI PROPERTY LOCATION <br /> ELDn ZY�1W 50 4 Y4 'Y4,S 35 T AQ N, R E (0 W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLoetE'r ` - J <br /> 2Z CNflKLA <br /> CITY,STATE ZIP CODE PHONE NUMBER S BDIVISION NAME OR CSM N MBER <br /> ffMM0ND 1 �'S ✓.i VOL__ I <br /> LDING: (Check one Lj CITY C I NEAREST ROAD <br /> 11. TYPE OF B <br /> ) ❑State Owned VILLAGE� O c 'RD <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms A ( ) G <br /> III. BUILDING USE: (If building type is public,check all that apply) Lt D-3 <br /> 1 ❑ Apt/Condo <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.,9 Replacement 3. ElReplacement 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 /> �����ttt <br /> 11 El Seepage Bed 21 ❑ Mound 30 El SpecifyType 4 Holding Tank <br /> 12 E] Seepage Trench 22 EJIn-Ground4 ❑ 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 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> �O <br /> REQUIRED(sq.ft.) PROPOSED s . Gals/day/sq.tt.) (Min./inch) ELEVATION <br /> Feet t <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istln Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks�MWj_L strutted <br /> Se tic Tankor Holdin Tank -�'+ "Kffirj <br /> Lift 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:IN S pa) MP/MPRSW No.: Business Phone Number: <br /> ,C ( Its 86b- yrs <br /> lumber's Address(Street,City,State,Zip Codd): <br /> Z'7 r,j 3s WEfsr W r, 3`431:5 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ,,,,,,������......ffffff Disapproved Sanitary Permit Fee(includes Groundwater [Date IssuedIssuing Age SI atu a Stamps) <br /> L(Approved ❑ Owner Given Initial C (�}Su�rcharge Fee) <br /> // \\ <br /> AdverseDetermination �3Js -v <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: / <br /> SBD-6399(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />