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17— oaaaaaaa`2 SANITARY PERMIT APPLICATION COUNTY ILHR In accord with ILHR 83.05,Wis.Adm. Code �iuC h <br /> STATE SANITARY PERMIT# JQ,J��a3 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than O 39 \ ww <br /> 8%x 11 inches in size. ❑ Check if revislooJ. 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. Q <br /> PROP RTY OWNER c^ PROPERTY LOCATION <br /> Te /� e A S �Y%4 Y4, S 3.? T3-7, N, R /I? E (or) <br /> PROPE OWNER'S M G ADDRESS LOT# BLOCK# <br /> ' e -e St. NF. <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> y <br /> /r1/M C OJ P;Aot <br /> If. TY Check one <br /> (OF UILDING: CITY / NEARES�`AD <br /> ) ❑State Owned 1 ❑ VILLAGE : Q/ <br /> ❑ Public 1 or 2 Fam. Dwellingof bedrooms 1X PA L I Ax <br /> III. BUILDING USE: (If building type is public,check all that apply) <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: (Check only one in line A. Check line B if applicable) <br /> A) 1. ❑ New 2. Z 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 22.9 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) ELEVATION <br /> 3 0 0 3 75— 3 7� L 3 �� 6 'Feet /60' "Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New istin Gallons Tanks oncrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank ZLo0 z000 j tI eY <br /> Lift Pump Tank/SI hon Chamber, oo I I k/' e .0 1 F1 I F1 F1 <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): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> /la c 44ar< <br /> Plumber's <br /> ,Address(Street,City,City,Striate,Zip Code):/ <br /> 6r4 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e issued Issui gent Sip re(No Stamps) <br /> ��p <br /> proved ❑ Owner Given Initial ` I�. fcharge Fee) ^�_ <br /> Adverse D t rmin tin oV Y <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 />