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COM—=—. 2HR SANITARY PERMIT APPLICATION <br /> COUNTY <br /> In accord with ILHR 83.05,Wis.Adm. Code <br /> STATE SANITARY PERMIT#1321.1 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than C(l(7t <br /> 8%x 11 inches in size. ❑ Check ifrevisiontop vious application <br /> —See reverse side for instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION ct <br /> ,,LION I , I% %,S ( � T,'3q , N, R 1 E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> Lo/p 1 <br /> CITY,STATE ZIP ODE y PHONE NUMBER Qq SUBDIVISION NAME OR CSM NUMBER <br /> IQ61A� I -D I <br /> If. TYPE OF BUILDING: (Check oneBit CITY NEAREST ROAD <br /> State Owned ❑ VILLATnWNGE ; US tIARTW <br /> LAC <br /> ❑ Public )M 1 or 2 Fam. Dwelling-#of bedrooms PARCEL TAX NUMB ) <br /> III. BUILDING USE: (If building type is public,check all that apply) <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) 11,New 2. El Replacement 3. El Replacement of 4. ❑ Reconnection of 5.El 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 ❑ 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 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> C(- ( © 1 432 . �fl Feet (J •J� Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdinct Tank �' %r$'fr <br /> Litt Pum Tank/Si hon 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:( o mps) MP/MPRSW No.: Business Phone Number: <br /> ep69(e-ic K u5 _ (?305 ?r5 Xk y(S� <br /> Plumber's Addrers's(Street,5 City,State, Code):.l E U( <br /> IX. COUNT'YIDEPARTM NT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Is i Agent Sig re(No Stamps) <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial p Q a <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6399(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />