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�ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COu <br /> f n,� <br /> • ­ STATE SANITARY PMIT# i 5ZS 7� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than r I.L-o \ S7 <br /> 8%x11 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 /> PROPERTY OWNER PROPERTY LOQATION ; i <br /> 5W '/a ) '%, S I1� T Q N, R I5 E (or W <br /> PFJOPERTY OWNER'S MAILING ADDRESS �� LOT# '31� BLOCK# <br /> 00 <br /> MTYLS_ JJE�V� i1� LIzIPCODE PHONE NUMBER SUBDIVISION NAME OR CSMNUMBER <br /> SST <br /> II. TYPE OF BUILDING: (ChecSk onleT CIN 7\V\ NEAREST ROAD <br /> State Owned YAWN E RF1j)(y�� W✓� I)ES 0 <br /> ❑ Public X1 or 2 Fam. Dwelling-#of bedrooms PARCEL TAX ER( ) ry r <br /> III. BUILDING USE: (If building type is public,check all that apply) <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. ElReplacement 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 /> 11-6 Seepage Bed 21 El Mound 30 El SpecifyType 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 DAY 2.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) �A ELEVATION <br /> 300 1 U 14 lZ 1 (0" 1 3 Feet %-0 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks MJr,ufacturer'sName oncret Con- Steel glass Plastic App <br /> Tanks Tanks L strutted <br /> Se tic Tank or Holdina Tank 01 4 S <br /> 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): Plumbs 's Sigr)at e:(VS ps) fMP/;M7jPRSw No.: Business Phone Number: <br /> bouldc <br /> Plumber's Address(Street, fly,State,Zip_pode): <br /> 2 11�rJ �p 3S WE 5aEIZ W j 7 Z <br /> IX. COU /DEPARTMENT USE ONLY <br /> Ej Disapproved I Sanitary Permit Fee(Includes Groundwater Date Issued Iss g gent Signa r (No Stamps) <br /> ❑ Owner Given Initial C harge Fee) <br /> Approved U -t� �p` <br /> Adverse Determination \0S 1— —l� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />