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17—DILHFt SANITARY PERMIT APPLICATION <br /> aaaaam%_ In accord with ILHR 83.05,Wis.Adm.Code couNry <br /> — - uro6,ff <br /> �M�• �_ STATESANITARY PERMIT#1g8�30 <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ❑ L�y�G�� O <br /> 8%x 11 Inches In size. Check if revi on 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. S _c;tc <br /> PROPERTY OWN R PROPERTY LOCATION <br /> �.1T S E'/4 tV jt.A/s,S & T3,1�, N, R 17 &(erjo <br /> PR RTYOWNER'SMMAIL,I/NG ADDRESS LOT# BLOCK# <br /> ITY,STATE ZIP CODE PHONE NUMBERSUBDIVISION NAME OR CSM N MBER <br /> eK rf. Ttj 1b0qqjCS'J'► U F. 1(iI in doet Lot <br /> 11. TYPE OF BUILDING: (Check one) ❑ State Owned CITTY Gnie <br /> NEARES ROAD <br /> 4PAW OF <br /> l.S Nr IES <br /> 12� <br /> 11Public l5p"i 1 or 2 Fam. Dwelling-#of bedrooms PWARGEL TAX NUMBER(S) <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) 1. ❑ New 2. I�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 Otherrtt <br /> 11 El Seepage Bed 21 El Mound 30 El SpecifyType 41 L&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 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Feet Feet <br /> VII. TANK CAPACITY Site <br /> inallons Total #of NPrefab. Fiber- Exper. <br /> INFORMATION New Feting Gallons Tanks Manufacturer's Name ConcreteCon- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank Holdin T Lift Pum Tank/Siphon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for i stallation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plum is Si Lure:IN Ste ) MP/MPRSW No.: Business Phone Number: <br /> N e(S� -e I h?,� �p�Y 7/S— <br /> Plumber'sZ A (Street.Ci tate,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date IssuedIssuing Agent Signature(No Stamps) <br /> �} r� Surcharge Fee) r� <br /> Approved ❑ OwnerGivenDetermin – 11i5s oD -14<1 <br /> Adverse Determination rmin tin " / �� LL'^'� '✓ <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />