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7�ILHR SANITARY PERMIT APPLICATION COUNTY <br /> _ In accord with ILHR 83.05,Wis. Adm. Code <br /> �~ mmmaw <br /> w STATE SANITARY PERMIT#IQ 163+ <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ (�e�39 <br /> 8%x 11 inches in size. Check Ifrevlsio o 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 PROPERTY LOCATION <br /> Tom/? C/ert� ec �w%42 '144 �/4, S � T zjte N, R H E (or)o <br /> PROPERTY NER'SM 1LING ADDRESS LOT III! BLOCK <br /> 512 /2T Gtl�l3r3�As<<c l <br /> CIN,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAM"R CSM NUMBER <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ❑ State Owned VILLAGE f�L�Y'f ,pnXy�� <br /> El Public 1 or 2 Fam.Dwelling-#of bedroo sa A L Ax: ER( ) _ � <br /> dvZo -C{30? ,0 � <br /> III. BUILDINGUSE: (If wilding type is public,check all thatap <br /> 1 ❑ ApVCondo -t L <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. F4 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 /> 11 LSeepage Bed 21 ❑ Mound 30 ❑ Specity 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 S EM INFORMATION: <br /> 1.GALLONS PER DAY 2. BSORP.AREA 13.ABSORP.AR 4. LOADING RATE 5. P RC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> /� R OUIRED(sq.ft.) PROPOSED(sq. .) (Gals/day/sq.ft.) ( in./i h) 1 ELEVATION <br /> 5CJ Cp/i 6 2 5 e / Feet 9��(C Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> IN New istin Gallons Tanks Manufacturer's a oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdinif Tank <br /> Lift Pump Tank/Siphon 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): Plum e:(No S MP/MPRSW No.: Business Phone Number: <br /> 0r+ ✓� 307 -- 7/-1- 2W- <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 'R r 5 Pzc5 70 LL//-2e C et)/,k- 5-e>e3 <br /> IX.1COUNTYIDEPARTMENT USE ONLY <br /> Disapproved Sapitary Permit Fee(includes Groundwater PaTe7es-557-1 Issuing Agent Signature(No Stamps) <br /> Surcharge Fee) <br /> (Approvetl ❑ Owner Given Initial <br /> Adverse Determinist! <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 />