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ILeassassalHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code couNTv <br /> ai�i� — <br /> � � STATE�ANITARY Pf RMIT#137243 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ( ( {Q 25 <br /> 8'%x 11 inches in size. ❑ Check if revision 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 /> PROPERTY0`"NER PROPERTY LOCATION <br /> 7/dC UL 5L` % SF %, S STN, R / E(or)(0- <br /> PROPERTY <br /> WPROPERTY OWN R'S MAILING ADDRESS LOT# BLOCK# <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 57--P 0L 12AI c501 45,3 V,51e- PT Gari. LbT�j <br /> 11. TYPE OF BUILDING: (Check one) El CITY NEAREST ROAD <br /> [IState Owned VILLAGE; �C y� <br /> ❑ Public 5?y or 2 Fam. Dwelling-#of bedrooms PARCEL TAX NUMB <br /> Ill. BUILDING USE: (If building type is public,check all that apply) qaa � (� -7690 <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. New 2. ❑ Replacement 3. ❑ Replacement of 4. El Reconnection of 5.❑ Repair of an <br /> ystem 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 /> 11eepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 El HoldingTank <br /> 12 eepage 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 PER2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 3L(,/,-y�DAY l® . 72W 95 9?'¢f Feet "Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding TankT <br /> Lift Pum 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): MP/MPRSWNo.: Business Phone Number: <br /> Plum natur ( tem s <br /> Plumber's Address(Street,City,State,Zip Code): <br /> /7r v �f3� ' w `. 3® <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e Issuin g Sin t re(No ps) <br /> I� Surcharge Fee) GQ <br /> A ❑pproved Owner Given initial \V <br /> Adv Determination V 1' <br /> CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6399(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />