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SANITARY PERMIT APPLICATION r <br /> �ILHA In accord with ILHR 83.05,Wis.Adm.Code DDUNTr <br /> STATE SANITARY-PERMIT#°1n 1ry-i� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ �� 00.J/bG3 <br /> 8%x 11 inches in size. c kfnevi toprevlousapplication <br /> -See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> PV '/4 w114,S Zg T31, N, R E(od@ <br /> P OPERTY OWNER'S MAILING ADDRESS LOT# j BLOCK# <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 32712Z W1 1-5-A9 It <br /> gar P- 84 <br /> It. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ��(( State Owned VILLAGE EE* <br /> ISI Public ❑1 or 2 Fam.Dwelling-#of bedrooms— <br /> Ill. BUILDING USE: (If building type is public,check all that apply) )?_ - 30.g_ <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursingjiame 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 RMerchandise: Sale epair 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 M ile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ElHotel/Motel 9 OHic 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. ❑ 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# ISSV9 Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 El Seepage Bed 21 PMound 30 EJ Specify Type 41 El Holding Tank <br /> 12 ❑ Seepage Trench 22h-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 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) <br /> (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 2 ( <br /> 7 FeetFeet <br /> VII. TANK CAPACITY Site ' <br /> in as 10 <br /> Total IPrefabFiber- Exper. <br /> . <br /> INFORMATION New istin Gallons Tanks Vo Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanksl Tanks strutted <br /> Septic Tank or Hold Tank <br /> Lift Pum Tank/Si hon Chamber <br /> VIII. 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 mps) MP/MPRSW No.: Business Phone Number: <br /> ltuvp 146nl <br /> lumber'sA dress(Street,City,State, ipC e' �^ <br /> 11-760 W 2! C$ <br /> IX. OUNTY/DEPARTMENT USE NLY K . WJ_4245`13 <br /> ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Ag SIu amps) <br /> Approved ❑ Owner Given Initial Surcharge Fee) <br /> rl- <br /> Adverse Determination � cc <br /> C <br /> r' INS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />