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I SANITARY PERMIT APPLICATION <br /> DILHR <br /> In accord with ILHR 83.05,Wis. Adm. Code COUNTY r <br /> =f9�{�.d'{NI11�IIr/�10.1�4 <br /> STATE WIITARY P MIT#la lk±5 y <br /> -Attach complete plans(to the county copy only)for the system,on paper not less thane <br /> 4 8 x 11 inches in size. I I Check II revision. 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 /> PRO E R OWNER�/ PROPERTY LOCATION <br /> ^ r71 2 /7 /) .5,KJ '/ 56%, S 7 T N, N, R /� E (or& <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 477 -rnt 3rd 5iireet /5 <br /> CITY,STA E ZIP CODE PHONE NUMBER SUBDIVI ION NAME OR CSM NUMBER <br /> .5, / /�� , 5 /Q, Oa )7?// 1 vet (al <br /> II. TYPE OF BUILDING: (Check one) El CITY / fj1TARES RO&D <br /> _ State Owned VILWLAGQEFy4)/0/7/y tei bYer /�,..,,,-,/Public %1 or 2 Fam.Dwelling-#of bedrooms .5 P R��L�dX (S) ` L/ 'C/ /'..C.t✓ <br /> III. BUILDING USE: (If building type is public,check all that apply) ,Z,- 91_5.j-. - 1C) <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 6 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 E Office/Factory 13 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. rg New 2. ❑ Replacement 3. ❑Replacement of 4. _ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) IT I 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 E 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 /> T5D ,/ C/ , 7/ 1 95,J Feet 9.5•? Feet <br /> CAPACITY Site <br /> VII. TANK in gallons Total #of Manufacturer's Name Prefab. Fiber- Plastic Exper. <br /> Con- Steel <br /> INFORMATION New Existing Gallons Tanks Concrete structed glass App. <br /> Tanks Tanks /v�� ��p(( <br /> Septic Tank or Holding Tank 1,/a) -- /� / 77 ❑ ❑ �,J ❑ E <br /> Litt Pump Tank/Siphon ChamberrL`11 ❑ '❑ ❑ <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 ignature:(No ps) MP/MPRSW No.: Business Phone Number: <br /> ii,/76k) . ,,,o,‘_ _ ,_,2 <-5,56V ( 7/5 )E6-i2'?P0 <br /> Plumber's�ddress(Street,City,State,Zip Cod6): <br /> Trent A/c.. 3. i°D. &x / rt/e, 7lP; it/2- .5z/F9,3 <br /> X. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Approved F Owner Given Initial <br /> Sanitary Permit Fee(Includes Groundwater a e s ue irr last gent Si e(No Stamps) <br /> j� /�(�Surcharge Fee) C <br /> Adverse Da erminati0n / S `-'`D -3‘) <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> t- <br /> SBD-6398(formerly Pib-87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />