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SANITARY PERMIT APPLICATION <br /> 70ILHR In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> _ �— utr e <br /> •��_ STATE SAyyy111��TARY PER T#l�/„�� <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than / D xx�i <br /> 8'%x 11 inches in size. ❑ Check f revlelon to wous applioatlon <br /> –See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. J, <br /> PRO TY OWNER / PROPERTY LOCATION <br /> PRO <br /> Ct Q c k 1✓'/414, S ,ST,3Ff , N, R (orffl <br /> PROPERTY OWNER'S MAILING ADDRESS ,�r�!/ LOT# �` BLOCK# <br /> 01 <br /> 1 � c�E Joic fiC', /V - 4 ± 4 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR SM NUMBER <br /> 11. TYPE OF DING: (Check one CITY NEAREST ROAD <br /> State Owned O VILLAGE <br /> ❑ Public 21 or 2 Fam. Dwelling-#of bedrooms� EL TAX NUM ER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) s� Q .� _ -2 <- 62 <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. lel 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 /> 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 5?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 PER2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> F� DAY REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 Feet Feet <br /> VII. TANK CAPACITY Ik <br /> Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New isms Gallons Tanf Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdina Tank 00o bD,; )Y1 « C- •Na re re <br /> Lift Pump Tank/Siphon Chamber <br /> Vlll. 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 Stamps) MP/MPRSW No.: Business Phone Number: <br /> a//aeC S e / J'1P - 3 7eS �6�-�G/ <br /> Plumber's Address(Street,City,State,zip Code): <br /> 141—le x5eval /u <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> 11 DisapprovedSanitary Permit Fee(Includes Groundwater ate IssuedIss Agent Signat a(No Stamps) <br /> Approved ❑ Owner Given Initial Q{ Surcharge Fed) <br /> Adverse Determination —r1 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 8 Buildings Division,Owner,Plumber <br />