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�DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY&.trn� <br /> • � STATE$ANITARERMIT#16 SZ{8 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than C IS-Wo3 <br /> 8'%x 11 inches in size. ❑ Check if revist6 to previous application <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 ATION <br /> 1r0.� �-Ya ''/a,S T , N, R E (orfW <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> Q <br /> CITY,STATE ZIP CODE PHONE NUMBER UBDIVISION NAME OR CSM NUMBER <br /> !A/ W .3 <br /> 11. TYPE OF BUILDING: (Check one 11 CITY ^- � NEAREST ROAD <br /> }�� State Owned VILLAGE �!/ 1W <br /> ❑ Public LF7�l or 2 Fam.Dwelling-#of bedrooms AX N�UUM <br /> III. BUILDING USE: (If building type is public,check all that apply) aCl' (41O7�I — 01-7 <br /> —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 2. 11y Replacement 3. El Replacement of 4. El Reconnection of 5.El Repair of an <br /> System K 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 9Seepage 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 13.ABSORP.AREA 14. LOADINGRATIE 15. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) I PROPOSED sq.ft.) (Gals/day/sq.ft.) (Min./i ch) // ELEVATION <br /> 5 / fOc Feet I feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New <br /> 1q <br /> Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdinct Tank <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sews a system shown on the attached plans. <br /> Plummer's Name(Print): Plu er' ignatu o Stam MP/MPRSW No.: Business Phone Number: <br /> // U 4 kR <br /> Plum rs Address(Street,City,StAte,Zip Code): 11 <br /> P2&1 clq6 0g1r ( 14). <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date IssuedIssuing gent Signature(No Stamps) <br /> A roved ,.4. Surcharge Fee) / / <br /> pp ❑ Owner Given Initial yy Ir-�J-` /HT1 �YC,.r �� „ <br /> Adverse Det rmin i n `-W V_ ) ��-�J W'i t- <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 8 Buildings Division,Owner,Plumber <br />