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01002 SANITARY PERMIT APPLICATION DILHR In accord with ILHR 83.05,Wis.Adm.Code couNTr <br /> F <br /> •�� STATE SANITARY P�ERMIT# <br /> -Attach complete plans(td the county copy only)for the system,on paper not less than /SANITARY <br /> a—t\ Ot 1 <br /> 8%x 11 inches in size. ❑ check if revlalo previous application <br /> —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMAT ON—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTYL ATION <br /> . . '/a, S � T I , N, R E(o W <br /> PROPERTY OWNER'S MAILING DDRESS LOT# BLOCK# <br /> 0 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> RO u V.!i 54 <br /> If. TYPE OF UILDING: (check one CITY NEAREST ROAD <br /> I <br /> LL ) State Owned VILLAGE: C S <br /> ❑ Public 541 or z Fam.Dwelling-#of bedrooms_ RNOLL Y1 ON u ( ) <br /> 111. BUILDING USE: (It builing type is public,check all that apply) 3;k-53G3'- 0L <br /> 1 ❑ ApVCondo <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: (Ch ck only one in line A. Check line B if applicable) <br /> A) 1. ❑ New 2. eplacement 3. ElReplacement of 4. ❑ Reconnection of 5.ElRepair of an <br /> System ! ystem Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit# — Date Issued <br /> V. TYPE OF SYSTEM: (C eck only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 Seepage Bed 21 El Mound 30 El specify Type 41 ❑ Holding Tank <br /> 12 ❑ Seepage Trench; 22 ❑ In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit I Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 12.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> rnrn <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Mi ./inch) 111. ELEVATION <br /> ,V r (p2 ( (0 Feet 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 Holdin Tank 'r <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume Qesponsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:( Stamps) MP/MPRSW No.: Business Phone Num er: <br /> IL �1K f <br /> lumber's ddr (Street,City, tate,Zip Code <br /> w W( . 5`01 <br /> IX. COUNTY/DEPARTI T US ONLY <br /> ❑ Disapprov d Sanitary Permit Fee(Includes Groundwater Date eau Issuing ent Signature(No Stamps) <br /> Surcharge Fee) <br /> Approved ❑ Owner GIN n Initial '135e <br /> A v rmin tion <br /> X. CONDITIONS OF APP VAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11(88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />