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_�DILHR SANITARY PERMIT APPLICATION COUNTY& <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> mom�• mo STATE ANITA YPERMIT#'QQ J�99DX�2 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ` <br /> 8%x 11 inches in size. 1:1 !L�ontoprevious 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 /> PROP TY OWNER PROPERTY LOCATION <br /> (r R FII✓ C S _5W 1/s S 36T N, R E (or(W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> Z 5 DFS Ct2c R- <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> U 4UE I� - 52ota 3 5 CS v ,)- P <br /> II ❑ State Owned VILLAGE. TYPE OF BUILDING: (Check one) CITY : NEAREST ROAD <br /> QUN OF: <br /> ❑ Public X 1 or 2 Fam.Dwelling—#of bedrooms ZPARCELTAX ) <br /> III. BUILDING USE: (If building type is public,check all that apply) �a _5 j �— 01--7/0 <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 ❑ 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. X 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 Seepage Bed 21 ❑ Mound 30 ❑ Speciy Type 41 El HoldingTank <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 13.ABSORP.AREA 4. LOADING RATE 5. PERC,RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REO IRED(sq.ft.) PROPOSED(sq.ft.) (Gals'/day/sq.ft.) (Min./inch) p �J pELEVATION <br /> 300 �D gQ [oz. 3 1 t'� Feet 17.7 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdinct Tank <br /> Litt Pump Tank/Siphon Chamber 11 1 L1 <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): Plum er's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> (oKlqF,n ao kfNS LAzro (S $ y(�7 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 2'7 '7 (00 H w WEssrER 8 <br /> IX. PARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e slue Issuing Age t Sign tura(No to ) <br /> Approved ❑ Owner Given Initial i <br /> Surcharge <br /> Fee) �/ <br /> Adverse De rmin tin '�j.0, `/ I <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly PID-87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety S Buildings Division,Owner,Plumber <br />