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DlL1HR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code c TM ,( <br /> " 4e me <br /> ���• � STATE SANITARY PERMIT#/ _4 ,7 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑(15,�-7 <br /> 8%x 11 inches in size. Check if reyl6lontopreviousapplication <br /> –See reverse side for instructions for completing this application. T E PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. �O – <br /> PROPER;Y OWNE PROPERTY LOCATION p <br /> QtS 02 r C Y4NE'/4, S 10 T37, N, R j �(9r W <br /> PROPERTY OWNER'S MAILING A DRESS, LOT# BLOCK# <br /> tel/OC s- <br /> C� w <br /> CITY,STT f ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Uj le WSW S�fn3 1(7/7964130f, <br /> It. TYPE OF BUILDING: (Check one CITY '�^,r NEAREST ROAD <br /> LJ Owned ❑ VILLAGE Y/`loPK ©%d k'7 <br /> ❑ Public �1 or 2 Fam. Dwelling–#of bedrooms3 PARCEL AX NUM R( ) J <br /> III. BUILDING USE: (If building type is public,check all that apply) 331 9 OI-Scc) <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 El 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. ❑ New 2. N 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 X Mound 30 F-1SpecifyType 41 El 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 2SORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> r / REQUIRED(sq.ft.) PROP�sq.ft.) (Gals/day/sq.ft.) (k}1indinch), ELEVATION <br /> �[- .7. • ' C,L !t( G// F-7 Feet 10;2,1,'5F a a I <br /> CAPACITY <br /> VII. TANK in allons Total of Prefab. Site Fiber- Exper. <br /> INFORMATION New tstin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> e k or Holdin Tank ) �b W r�' �' <br /> ift Pu TanWSi hon Chamber 44 1 7SC9 I / 1tv 7 FS�pY Gr-2 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility fo installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name Print o: Plu bar's nat e: Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's dress(Street, �,Stat ,Zip Codel <br /> IX, COUNTY/DEPARTMENT USE ONLY}\/ /YJ,Si�n <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e Issuedles Agent Sign a(No Stamps) <br /> Approved ❑ Owner Given Initial �--/ y Suroharge Fee) <br /> Adverse 1 !Q - - J4 �_7U . W' <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/89) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />