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alliss" SANITARY PERMIT APPLICATION COUNTY rn <br /> 170—ILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> �• �- <br /> STATESANITAIkY PERMIT## <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �15f5a3 '' <br /> 8'%x 11 inches in size. ElCheck if re ion 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 PROPEfTY OCATI ON <br /> Yfn�C. �'�+ EZ t1A/'/a '/e,S T , N, R / E(o W <br /> P_O ERN OWNER'S (LING ADDRESS LOT# BLOCK# <br /> Z D <br /> CITY STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> CSm ti'. 41 /`,l g'ov't. Loth <br /> II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD <br /> ❑ Stat@OWned 22 VILLAGE') N( 11NBA RD _ <br /> ❑ Public o1 or 2 Fam. Dwelling-#of bedrooms 2 PARCEL TAX Nu BE ?� y <br /> 111. BUILDING USE: (If building type is public,check all that apply) ' — ;;�. L— V — <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, E] New 2.�Replacement 3. ❑ Replacement of 4. El 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 ❑ Holding Tank <br /> 1 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 DZI 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED_(sq.ft.) PROPOSED <br /> �(sq.ft.) (Gals/day/sq.ft.) (Min/inch) ELEVATION <br /> JL <br /> U 1-- I Feet Feet <br /> VII. TANK CAPACITY Prefab. Site Fiber- Exper. <br /> in allons Total #of Manufacturer's Name Con- Steel Plastic <br /> INFORMATION New istin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holdin Tank �' F-1 Fj F1 F1 <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): PI b rs Signature:(No amps) MP/MPRSW No.: Business Phone Number: <br /> I <br /> ICNA� oPrUNS T-5 <br /> Plumber's Address(street,City,State,Zip C ): w ,„ <br /> 2-`7'760 Iwo 35 E$ 1 i� lj� . T <br /> IX. COUNTY/DEPART ENT USE ONLY Issuin gent Signature(No Stamps) <br /> ❑ Disapproved Sanitary Permit Fee uncivaea oroundwater a e ssue 9 - <br /> SurMargeFee) (l 13_ I ,n , ^ <br /> Approved ❑ Owner Given Initial Qt I OC � ls.�-ter l� <br /> Adv rse Determination <br /> `+f' J <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 />