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O �ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STATE SANITARY PERMIT# 1- <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ( 1 H3L, 50 <br /> 82%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 /> PROP RTY OWNER PROPERTY LOCATION <br /> 4� Lown sWY4 /VW %4, S 30 Ty/ , N, R �' E (o W <br /> PROPERTY OWNER'SMAILING ADDRESS LOT# BLOCK# <br /> 86 � W6jL/0,W O/ PA <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 4 Sou W If 0/ CS Z S <br /> Cl <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLAGE NE REST ROAD <br /> ❑ Public [&1 or 2 Fam. Dwelling,#of bedrooms 2_ OR L UM ER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) G 3Z _ S I C) <br /> 1 ❑ ApVCondo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranVBar/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. ❑ 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 ❑ 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 7 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERCRATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> c� REQ/UIRED(sq.ft.) PROPOSED(sq.tt.) (Gals/day/sq.tt.) (Min./inch) r ELEVATION <br /> J lD <br /> Ir (D 3 -2 J– ,d Feet 01 Feet <br /> VII. TANK CAPACITY Site <br /> INFORMATION in allons Total #of Prefab. Fiber- Exper. <br /> New istin Gallons Tanks Manufacturer's Name Cone Con- Steel glass Plastic A <br /> Tanks Tanks structed pp' <br /> Septic Tank or Holding Tank Ogd ( 1 LSC <br /> Litt Pum Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plu 's Siignature:/(1�'�o Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's ddr (Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ry/ Disapproved Sanitary Permit Fee (Includea Groundwater Date Issued Issuin gent Signature(No Stamps) <br /> LVI N roved Surcharge Fas) <br /> pp ❑ Owner �I^�60 - �_�-Z�q L <br /> Adverse Determination tin v I <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 />