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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTY <br /> �ILHR <br /> •��- STATE SANITARY PE IT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than / jL45� �� �� � <br /> � <br /> 8%x11inches Insize. ❑ cnec 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 /> P59TRTY OWNER PROP !LOCTION <br /> Ud/art • G'� �� /a, S T N, R ��(7 E(or WP OPERTY O ER' AILING ADDRESS LOT# BLOCK# <br /> 35CITY,STI ��/T ZI QQE&, P ONE UMBER SUBDIVME OR CSM NUMBER <br /> II. TYPE OF BUILDING: (Check one) CITNEAREST ROAD <br /> State Owned VILLAGE <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms L ERO <br /> Ill. BUILDING USE: (If building type is public,check all that apply) r�/t/_331 -- <br /> � —�V v <br /> 1 ElApt/Condo r <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. IxReplacement 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 El Mound 30 ❑ SpecityType 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 SYSTEM INFORMATION: <br /> 1.GALLONS PER U1 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> 3..(J <br /> REQUIRED(q.ft.) PROPOS D(sq.ft.) (Gals/day/sq.y/sq.ft.) (Min./inch) // ELEVATION <br /> 5 <br /> ✓?A7 ��• y Feet D .,,3 Feet <br /> VII. TANK CAPACITY Site <br /> in <br /> pre <br /> VII. Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New istin Gallons Tanks oncret glass App. <br /> Tanks I Tanks structed <br /> Septic Tank or Holdina Tank 17M I —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): Plumber's Signature:(No S s) MP/MPRSW No.: Business Phone Number: <br /> ) CE. &7�1'�)111 lir/ 30/ 7/S Lily- 7o?S� <br /> Plumber's Address(Street,City,State,Zip Code): <br /> O. (t& 11 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Igi gent Signa a(No Stamps) <br /> Approved ❑ OwnerGiven initial arge Fee) <br /> Adverse Dtermi -$ '0 <br /> 5s Suroh <br /> rf a <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />