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�ILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code 8 u I-n e f4- <br /> TATE SANITARY PERMIT <br /> 4- <br /> STATESANITARYPERMITIq��� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �4 'F.l fcG,7 o\\ <br /> 8%x 11 inches 1n size. ❑ Check If revision to previous sopica#fin <br /> -See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PRO ERTY OWNER PROPERTY LOCATION <br /> latrt'k -L)a11 ' ,vE'/4 t='/4,S .2(oN, R $ W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> ,;L3 ?- d <br /> CITY,STATE ZI DE I PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> CITY p i NEAREST <br /> II. TYPE OF BUILDING: (Check one) RonD O II <br /> State Owned VILLAGE oba t�lYl C{ pS$daW� 2Q <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms3 L AxN ( ) <br /> 111. BUILDING USE: (If building type is public,check all that apply) ILn.-. <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: (Checkonly one in line A. Check line Bit applicable) <br /> A) 1. ❑ New 2. X 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 PE2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> � , R DAY REQUIRED AREA <br /> ft.) PROPOSED(sq.h.) (Gals/day/sq.ft.) (Min./Inch) ELEVATION <br /> LIv Tv Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New is <br /> Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank o oldin Tan 000 � W,eSer C <br /> Lift Pum Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility fo installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plu bar's Signatu e:( oStamps) MP/MPRSWNo.: Business Phone Number: <br /> k-e tS o-eF r WrP S��t/ 7� s b 6-01 <br /> Plumber's Address(Stree,City,State,Zip Code): <br /> �S C VJefaS�� 5� <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(imiudesGroundwater Datessu Issuing, ent signs ure(No Stamps) <br /> �r}� Surcharge Fee) ' <br /> Approvetl ❑ OwnerL%liLQen Initial -34 l a5,�-p--� _ ,Q,@� -7')')a4. <br /> A v roe De rmin tion .•����..JJ ll�/ <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />