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j� SANITARY PERMIT APPLICATION <br /> t] 0ILHR In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> �M�• � STATESANITARY5to <br /> ERMIT#/ 15'�(v <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than SA 8'%x 11 inches insize. ElCheck it reviai 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 /> PyR-OPERTY pWISER / LPARCELTAXNiUMBER(S) <br /> ATION <br /> C.i fl 1.CRc /1, '/4,S .2$' TYO , N, R /.�E (o W <br /> PROPERTY O ER'S MAILING ADDRESS BLOCK# <br /> CIN,STAT ZIP CODE PHONE NUMBERAME OR CSM NUMBER <br /> 60J' /� tI <br /> IL TY E OF BUILDING: (Check one �OWU OF 'tip NEAREST ROAD / <br /> ❑$tate OWnedG S+4t d L,e r i <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedroomU ER( ) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) ( cq-( a15-o3_ <br /> 1 ❑ Apf/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. El Replacement 3. El Replacement of 4. ❑ Reconnection of 5.El 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 ❑ Specify Type 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 31 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./ h) <br /> ELEVATION <br /> d Q F1 c) .S U ' Feet �-� / Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Expp. <br /> INFORMATION New istin Gallons Of Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdin Tank ) 00 ) W C <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): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> 0 3 v lir x'66 yes 7 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> �_o l.l} <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(includes Groundwater ae ssue Ise g ent Signatur N tamps) <br /> Approved ❑ Owner Given Initial /�� surcharge reel <br /> Adverse Dr in ti n <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8393(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />