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�D14HR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couluTv <br /> _ � � r �� <br /> STATE SANITARY PERM # ,r�h5 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ //5 t-j 7,y <br /> 8'%x11inches insize. Check vision to reviousapplication <br /> —See reverse side for instructions for completing this application. STATE PLAN I.D.,UM BER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. fir# <br /> PROPERTY OWNER JPROPERTYrLOCATION K % _5IE. Ya, S Z T VQ, N, R t/_ E (or WPROPERTY OWNER'S AILING ADDRESS # h BLOCK# <br /> STATE 21PCODE HONE NUMBER �L' X74 <br /> . S's z 2 -II. TYPE OF UILDING: (Check one) CITY NEAREST ROAD <br /> State ownedVILLAGE TOWN OF:tAKt hV CCc <br /> ❑ Public 1 or2 Fam. Dwelling-#of bedroomsPARCEL TAX NUU S <br /> /� pps'' C7 <br /> 111. BUILDING U E: (If building type is public,check all that apply) �V <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. TYY 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 /> 11SeepageBed 21 ElMound 30 El SpecifyType 41 El HoldingTank <br /> 12 F 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 PEW7 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) E�'L^EVATION <br /> 1150 (20 14 Zr25Feet J, Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank >y 000 /LS <br /> Lia Pum Tank/SI hon Chamber In 0 <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): Plumb is Signature:(No temps) MP/MPRSW No.: Business Phone Number: <br /> o��� s 3Ll ? 5 b - <br /> lumber's Address(Street,91ty,State,Zip Code)* <br /> dwv 35 I,Jza515 R. w i. SV993 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved nitary Permit Fee(Includes Groundwater Date Issued Issuing Surcharge Age ignatu (No a ps) <br /> Feel //'J <br /> Approved ❑ owner Given Initial � �i� <br /> TTT"' A v rs Determinati n <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 />