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7DILHR SANITARY PERMIT APPLICATION COUNTY�� <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITAPERMIT# 6JC2 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than J <br /> 8%x 11 inches in size. ❑ r6��'J(0 <br /> eck if re ft on to previous application <br /> ,S@@ rBVefSB SIdB for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTYLO ATION <br /> /f/ Ls7/Lli 6 L '/4 '/4, S T N, R / E(or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> c77z /21) ,,/, 3 <br /> CITU,STATE ZIP CODE PHONE NUMBER SUB IVISION NAME OR CSM NU BER <br /> J to <br /> r,/l a?o CSrn U. a I 3— <br /> If. TYPE OF BUILDING: (Check one) ❑State Owned GILUGE a NEAREST ROAD <br /> S�v e /2U - <br /> ❑ Public JK1 or 2 Fam. Dwelling—#of bedroomsa IIAWYORU ) f <br /> Ill. 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 ❑ RestaurantfBar/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. ❑ New 2. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System stem 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 El Mound 30 El 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 2.ABSORP.AREA 3.ABSORP.AR 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> Oo� REOUIR 0(sq.ft.) PROPO D( .ft.) (Gals/day/sq.ft.) (Min <br /> .A h) ELEVATION <br /> �v0 r ` I a <br /> 2� Feet / Feet <br /> VII. TANK CAPACITY ISite <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App <br /> Tanks Tanks structed Plastic <br /> Septic Tank or Holdin Tank 7 50 1W C�$c 7L. <br /> Lift Pump Tank/Siphon Chamber <br /> Vlll. 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): Plum lure: 0 mps)..- MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> R T ?5 1 a-) 0 /�/�/ C�� w ` • S�C€�30 <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(includes Groundwater a e Issued Is n Agent Sig tura(No Stamps) <br /> kPP <br /> roved ❑ Owner Given Initial I O�e surcharge Pee) ` � t r <br /> Adver rmin lin t /71 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> 51313-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />