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_ SANITARY PERMIT APPLICATION COUNTY <br /> pILHR <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> A..�.,,.e...mmm STATE SANITARY PERMIT# \ <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ I a I E��— (1q)LjS <br /> 614 x 11 inches in size. Check if revisidn to previous app iication <br /> —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> c Rqc r4J'/s I%,I '/a, S TgO, N, R (or(or W <br /> PROPERTY 091 MAILING ADDRESS &X ^2 LOT# BLOC# <br /> CITY,STATE St..-rblR d/IS ZIP CODE PHONE NUMBER SUBDIVISION.NAME OR CSM NUMBER <br /> II. TYPE OF BUILDING: (Check one) Li <br /> �ITY NEAREST ROAD <br /> ❑State Owned VILLAGEi �/ Pn * 3 J <br /> ❑ Public 011 or 2 Fam. Dwelling–#of bedrooms AR EL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) _C �.P�n._ - //-o <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 ❑ Service n tion/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. [4 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 PERDAY 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 kh try I & q P 1 1. 9 <1V Feet 97-1 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New Istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank I WoLfeUQ: ( I WC <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): Signature: oStamps) MP/MPRSWNo.: <br /> ' PM <br /> er's Business Phone Number: <br /> lR4 Icf"SOS /d' yhE. l� <br /> Plumber's ddress(Street,City,State,Zip Code): <br /> ti <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(11 11 Groundwater a e ssue Isa ' g gent Sig t (No Stamps) <br /> � Surcharge iee) I �. <br /> Approved ❑ Owner Given Initial I V"/o F}r._ I /_ _. <br /> A D term) i n lf-' lJV 'l <br /> X. CONDITIONS OF APPROVALIREASONS 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 />