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�ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> wo STATE,,,SSSANITA YPERMIT O#'LGqIq <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ / 'S67� J <br /> 834 x 11 inches in size. c eck if rev on to previous application <br /> —See reverse side for instructions for completing this application. STATE PLAN f.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> P PERTY OWNER P OPERTY LOC TION n <br /> G N Z '/a Su'/a, S T O, N, R 5 E(orkW) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# t 1 BLOCK#�� <br /> V NEi I Cl T <br /> CITY,STATL %q 14KK IP�E PHONE NUMBER SUBDIVISION AME OR CSM N EisqEL Add, <br /> V / <br /> If. TYPES OF BUILDING: (Check one) ❑State Owned VILLAGE: NEAREST ROAD �/ <br /> oN YL <br /> ❑ Public A, or 2 Fam. Dwelling-#of bedrooms PARCEL I AX NUMBEH(b) <br /> III. BUILDING USE: (If building type is public,check all that apply) 1 a-G3as- /()-400 <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. ❑ Replacement 3. El Replacement of 4. ❑ Reconnection of 5.El 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 /> 11Seepage 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 7 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> RE UIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Q ELEVATION <br /> 3©© 1 1 Feet J Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdino Tank <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 /> P mber's Name(Print): PI be 's Signature:(No S ps) MP/MPRSW No.: B ness Phone Number. /� <br /> I� 0 11TUAW <br /> lumber'i dress(Street City State, C ):0PSt6Z Lk <br /> VV <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved I SanitaryPermit Fee(Includes Groundwater a e IssuedIssuing Agent Signature(No Stamps) <br /> Approved /V� Surcharge Fee) �}''� <br /> ❑ Owner Given Initial f 05011../ -'�v-9l . <br /> I Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />