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SANITARY PERMIT APPLICATION COUNTY <br /> DILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITARY PE IT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than 1l4a4T (f4/y(,) <br /> 8'%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 /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROP RTY OWNER PROPERTY LOCATION <br /> / �Q/� S� ''/4511,'/4, S .3-3 TV/, N, R/7/ (or)® <br /> PROPERTY OW R'S ILING ADDRESS LOT# BLOCK# <br /> e �IB/vd. 90v,` , Lot S <br /> CITY STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> l/rva>�i 172e �57-50Z� loia <br /> II. TYPE OF BUILDING: (Check one) CITY NE REST ROAD <br /> ��y(( ❑ State Owned ?? QF <br /> VILLAGE �l � / <br /> ❑ Public I�.I 1 or 2 Fam. Dwelling-#of bedrooms PARCEL TAX NUM ( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) Q -,5`333 —03— ?00 <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. V Replacement 3. ❑ Replacement of 4. ElReconnection 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 /> 11Seepage 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 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV, 7. FINAL GRADE <br /> y� REQUIRED(sq.ft.) PROPOSED(sq.tt.) (Gals/day/sq.ft.) (Min./inch) �J ELEVATION <br /> Vst/ 6/� (o3D . 7 / Feet Feet <br /> VII. TANK CAPACITY Site <br /> in <br /> 110 TY <br /> Total #ot 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 Hol din Tank � LOCA e <br /> Litt Pum 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'' SignatuMP/MPRSW No.: Business Phone Number: <br /> e &1>� /m ( 4W,/ re:( Stamps) 33Co/ 11/S Plnlo- 7��1P <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Trou/Ale. 5. >°O. �X /03 cc/&,62 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee(Includes Groundwatera e ssue Is AgeAt Sign r (No Stamps) <br /> L, <br /> Approved F-1 Owner Given Suharge Fee)Initial q�' �0 iO.�j y—q_v9' <br /> Adverse D rc <br /> rmin tion W VI <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD4M8(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />