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[� SANITARY PERMIT APPLICATION COUNTY <br /> U OILHA In accord with ILHR 83.05,Wis.Adm.Code R � �ett <br /> �M�• � STATES NITARY ERMIT#�� �7; <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �1, eI <br /> 8%x 11 inches in size. ❑ Check if revi on to previous applicatlon <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 OWNER PROPERTY LOCATION <br /> Elv N� 1n/ '/,$1�/'/s, S 27 T 0, N, R (o E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 2 G� A <br /> CITY STAT ZIP CODE PHONEtOb . � SUBDIVISION NCAME OR CSM NUMBER jn f L LG-L s <br /> 11. TYPE OF BUILDING: (Check oQCnTleAl) IIYY CITY NEAREST ROAD L <br /> ❑ State Owned ��// VILLAGE OWN '^A KLI94t> <br /> El Public 1or2Fam. Dwelling-#ofbedrooms L L ( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) a© 43jo 7- <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 2X 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 Other <br /> 11Seepage Bed 21 ❑ Mound 30 ElSpecify 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 /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) �J G ELEVATION <br /> 30 o �© ♦tG2 5 -1 • ! Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allona Total #Of Prefab. Fiber- Exper. <br /> INFORMATION New is in Gallons Of Manufacturer's Name ConcreteCon- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank �- <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:(No mps) MP/MPRSW No.: Business Phone Number: <br /> BCH R) OPKAJs Lf24> 1 (]rS <br /> Plumber's Address(Street,City,State,Zip Code): <br /> w 35 WF35TER Wt . <br /> IX. COUNTYIDEPARTME T USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing A e Signature(No Stamps) <br /> �y <br /> Approved ❑ Surcharge Fee) <br /> Owner Given Initial ¢( JOJ[ <br /> Adverse rmin tin —L{� I <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />