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1 53ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code c"" <br /> STATE SANITAR PERMIT#/at�J7j <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ �� �� <br /> 8'/z x 11 inches In size. eck if revs ' n 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 tPROPE]RWYOCATION 'r t � 14, S36 T Y N, R ARE(orPROPERTY OWNER'S MAILIN .A-/D�DRESS BLOCK# <br /> S' 6a ( A4 eW1 vA <br /> CITY,STATE ZIPCODE PHONE NUMBER NAME OR CSM NUMBER <br /> At Cs f N . i s >;'a IWI CITYII. TYPE OF BUILDING: (Check one) ❑State Owned LLAGE �� S NEAREST ROAD <br /> C �� <br /> ❑ Public �1 or 2 Fam. Dwelling-#of bedrooms� AR ELTAx NUM <br /> 111. BUILDING USE: (If building type is public,check all that apply) - - q/r_S�— <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 ❑ 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 DAI 2.ABSORP,AREA 3.ABSORP.AREA 4. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Y 3 c,3 / 6�/^7 Feet /0 10 Feet <br /> VII. TANK CAPACITY Site <br /> in al Ions Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New ting Gallons Tanks Concreteglass App. <br /> Tanks Tanks structed <br /> Septic Tank orHoldin Tank 7$O 7`-ML <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): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> /Pe ,� o <br /> Plumber's Address(.tree,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved I Sanitary Permit Fee(Includes Groundwater ate IssuedIssuing Agent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial surcharge Fee) <br /> Adverse D t rmin tin �05' ) r,_0 <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 8 Buildings Division,Owner,Plumber <br />