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�DILHF2 SANITARY PERMIT APPLICATION <br /> In accord With ILHR 83.05,Wis.Adm.Code COUNT <br /> STATE/$ANITARXPPERMITaapllatj3 <br /> -Attach complete plans(t�the county copy only)for the system,on paper not less than l )1393 J <br /> 8'%x 11 inches in size. ! <br /> Check If revision to previous application <br /> -See reverse Side for instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMA ION–PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> AiiY d CJ IN UF '/4/U GL/%,S T3?, N, R � W <br /> PROPERTY OWNER'S MAILINGADDRESS LOT# BLOCK# <br /> iLl dr+th tfur2 ZYIVc <br /> CITY,STATE ) ZIP, 'f' <br /> CODE Y/,,, PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 6-Y LA✓I tS T e � 71S & 37,;3 <br /> IL TYPE OF B LDING: (Check one) ❑State Owned VILLAGE NEAREST ROAD <br /> M TOWN A ?1'V401 64 94, M <br /> ❑ Public ®1 or 2 Fam.Dwelling,#of bedrooms PARCEL TAX Nu <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. I$New 2. ❑ 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 R Seepage 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 j2.ABSORP.,AREA 3.ABSORP.AREA 4. LOADINGRATE 5. PERC.RATE 6. SYSTEMELEV. 7. FINALGRADE <br /> RE UtIRED( q.ft.) P�R/OPPO., c]-1 PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> ©� 0 <br /> 7 `f 0 O •�c • �.5.� t t,IV Feet J&03 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tankof Holdino Tank 0� �I <br /> Lift Pump Tank/Siphon Chamber <br /> Vill. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name , Plu tier's Signature (N mps) MP/MPRSWNo.: Business Phone Number: <br /> ( k s� WE / S W6- <br /> lumber_79-��esa(Sire t,City ,tate,Zip Cade): ` <br /> Add <br /> if <br /> IX. COUNTY/DEPAR E T USE ONLY f/(! <br /> Disapprovi I Sanitary Permit Fee(Includes Groundwater Date Issued Issui gent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial ^13`J -y-�roharge Fee) <br /> A D i'termin tin �-~1 0 l <br /> X. DITIONS APPR VAL/REASONS FOR DISAPPROVAL: � <br /> lo p /-11,1e ,a To 6P cLa�e o a-� S <br /> �. <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety8 Buildings Division,Owner,Plumber <br />