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QILHR SANITARY PERMIT APPLICATION ffSAN"RY <br /> _ In accord with ILHR 83.05,Wis.Adm.Code <br /> R IT#Iq <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8%x11 InchesInsize. o revious application-See reverse side for instructions for completing this application. //� BER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. Ipg 02013 <br /> PROPERTY OWNER rPROPERTYLOCATIONC o �l . ''/.SLI ''/a, S T ��, N, R AE (o WPROPERTY OWNER'S MAILING ADDRESS BLOCK# I36bo V,62 Rd r� +�CITY,STATE ZIPCODE PHONE NUMBER IVI ION NAME OR C NU BER fate <br /> ITY NEAREST ROAII. PE OF BUILDING: (Check one) ❑ State Owned ILLAGE: 0n A1411V <br /> Public ❑1 or 2 Fam.Dwelling-#of bedrooms— REL NUMB ) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) C-��7J- �?Q c;)v v <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ppp❑IpIIII 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 u Office/Factory 13 ❑ Other: Specify <br /> IV. TYPEOF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. NJ 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 /> 11Seepage Bed 21 El Mound 30 ❑ Specify Type 41 El Holding Tank <br /> 12 Seepage Trench 22 19 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 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> -X,"C REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 3 y�py/LLEVATION <br /> ao 4f v - - 93 Feet /f0• O Feet <br /> VII. TANK CAPACITY <br /> in allons Total #o /o trerPreta3, Site Fiber- Exper. <br /> M <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Se to Tank or Ho"d"n Tank gar" b a <br /> Lift Pum TanklSi hon Chamber 0 <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): Plu bar' Sig lure: Stamps) 9WMPRSW No.: Business Phone Number: <br /> ,�, 33ogf 7�J— `/ ,� - 7�0 <br /> Plu bar's Ad essO(3\treet,City,Slate,Zip Code):G <br /> IX. COUNTYIDEPARTM LENT USE ONLY <br /> ❑ Disapproved sanitary Permit Fee(Includes Groundwater a e ssue Issu"n Agent signature(No Stamps) <br /> O� . L7— Fee) �i n <br /> Approved ❑ Dwner Given Initial <br /> Adv rs Determination <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-MB(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety8 Buildings Division,Owner,Plumber <br />