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LHR SANITARY PERMIT APPLICATION . COUNTY <br /> IjEffIn accord with ILHR 83.05,Wis. Adm. Code <br /> Monsoons <br /> x 11 inches in size. C k STATE�A ITA PERMIT III Z <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ <br /> 8'fi if revi n 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 PROPERTY LOCATION <br /> if O'CeA T 6>&7/fo7 Ya, S 1,3 T443 , N, R / /rE <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# y BLOCK# <br /> /V / • �O <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Aill"YEi o Gr KE .c'� i¢ -E/fC <br /> It. TYPE OF BUILDING: (Check one CITY NEAREST ROAD <br /> > ❑State Owned ❑ VILLAGE SC ej``r <br /> I�� ,p cit�6 �t':[IE <br /> ❑ Public P or 2 Fam. Dwelling-#of bedrooms Z- PARCEL A (EyR( ) ^ <br /> III. BUILDING USE: (If building type is public,check all that apply) „( X_ (/l� O� _g <br /> oo <br /> 1 ❑ Apt/Condo v lV 111 <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. ew 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ® o ding 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 PER7 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Feet Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank !Y� <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): Plumber's Signature: Stamp) AV/MPRSW No.: Business Phone Number: <br /> C•L ^(G/e[ C I Rbc _ <br /> Plumber's Address(Street,City,State,Zip Code): <br /> /1 �ON 6LG Zi <br /> IX. gOUNTYIDIEPARTMENT USE ONLY <br /> Lj Disapproved S nitery Permit Fee(i1 <br /> mhae Grountlwater Date eau Issuing Agent Signet re(�,o S amps) <br /> Sun;herge Fee) <br /> pe proved ❑ OwnerDeal <br /> Adverse D t termi rmin <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6399(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />