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IHR SANITARY PERMIT APPLICATION co NTYA �n — <br /> In accord with ILHR 83.05,Wis.Adm.Code 140,1 <br /> STT SANITq�\RY PERMIT# x. <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than FS, <br /> 8'%x 11 inches in size. Check if revision to previous application <br /> -See reverse Side for Instructions for completing this application. ST TE PLAN I.D.NUM ER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. "( ?I� <br /> PROPIERTY OWNER PROPERTY LOCATION <br /> I df '/4 ''/4, S T N R E(or W <br /> PROPER O ER'S MAILING ADDRESS LOT# BLOCK# <br /> 2 $S o - <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 22A RIIIZ� W 1, 30 S ?S - ro <br /> II. TYPE OF B ILDING: (Check one) ❑State Owned CILLAGE ITY : EA EST ROAD <br /> c 1 LKXI;;E <br /> Public1 or 2 Fam. Dwelling-#of bedrooms— AN= <br /> CIELTAXISIUM ( ) <br /> 111. BUILDING USE: (If building type is public,check all that apply) Gl -C(L 1 -cc) <br /> A21 Apt/Condo <br /> Assembly Hall 6 ❑ Medical Facility/Nursing Ho 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 El Merchandise: Sales/Re 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ElMobile Home Park 12 ElSe vice Stat! n/Car Wash <br /> 5 ❑ Hotel/Motel 9 ElOffice/Factory 13 ❑ Othev-5poFify <br /> IV. TYPE OF PERMIT: (Check only one in line A. C k line I a ) <br /> A) 1. New 2. ❑ Replacement 3. a nt o 4. Reconne ' of 5.❑ Repair of an <br /> System System nk y Existi ystem Existing System <br /> B) ❑ A Sanitary Permit was previo sued. P mit Date Wai led <br /> V. TYPE OF SYSTEM: (Chec one) <br /> Non-Pressurized Distri ion ssuriz Distrib n rimen Other <br /> A11 Seepage Bed 21 Mou 30 ❑ S pe 41 ❑ Holding Tank <br /> eepage Tr h 22 ro d 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pres r • 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYS FOR ION: <br /> 1.GALLONS PER DAY 2.A OR REA 3. SORP.AREA 14. ADING RATE 5. PER'.RATE E. SYSTEM ELEV. 7. FINAL GRADE <br /> REO sq.ft.) OPOSED(sq.ft.) (Gals/day/sq.ff.) (Min./inch) Q O ELEVATION <br /> 200 1 1Z$ _ - C)I • o Feet 3 Feet <br /> VII. TANK PACI Site <br /> in al s Total #of Prefab. Fiber- ExPp. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tan Tanks ��7nn structed <br /> Septic Tank or Holdin Tank D LdIbD W <br /> Lift Pum TanWSi hon Chamber <br /> VIII. RESPONSIBILITY S TEMENT <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 She ) MP/MPRSW No.: Business Phone Number: <br /> ) o o KIIJs 3�ZG11,5 ) $66- ISS <br /> Plumber's Address(Street,city,State,Zip coof): <br /> 27760 #wx 35 W5TK9W1. �{gcJj <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Lj Disapproved Sanitary Permit Fee(Inciudes Groundwater Date Issued Issuing a tSi at o mps) <br /> Approved ❑ Owner Given Initialrcharge fee) �� N <br /> Adverse Determination <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, mer,Plumber <br />