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SANITARY PERMIT APPLICATION `� <br /> 70ILHR In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> mmoins NU <br /> 132543 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE SANITARY PERMIT# <br /> ty kgs) <br /> 834 x 11 inches in size. ❑ Check if revision to previous application <br /> -See reverse Side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROP,gIRTY OWNER USUBDIVISION <br /> OCATION <br /> '/4, S "BLOCK <br /> N, R (6 E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS # <br /> o RPS_ RUE , I cmv, Lai <br /> CITY,STATE ZIP CODE PHONE NUMBER NAME OR CSM NUMBER <br /> Sur I �Bo csrn i to 1 q <br /> 11. TYPE OF BUILDING: (Check one) ❑State Owned Li LLAGE: NEAREST ROAD <br /> t Sw(ss i_PKt Lko)K- RI�- <br /> ❑ Public Z1 or 2 Fam. Dwelling-#of bedrooms2- AX NUM FR(5) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) `J�JZ. ` � \ }O <br /> 1 ❑ Apt/Condo l <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 /> 111.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 DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. FERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.tt.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 13 4M 432 . bC 3 QTS^ Feet 2 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New istin Gallons Tanks oncret glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holdino Tank i ISO L <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): I Plumber's Signature:(No S mps) MP/MPRSW No.: Business Phone Number: <br /> Zh <br /> ,ck 9 k(Ns �� 0�°�9 l►5 8be- q(sl <br /> P umber's Address(Street,yty,State,Zip code): <br /> 2:116 o w 3S W)f_e>51'6R1, W( <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> DisapprovedSanitary Permit Fee(Includes Groundwater Date ssu Issu' g pent Sig re(No Stamps) <br /> Approved ❑ Owner Given Initial TC surcharge Fee) ( � ,,( Q <br /> Adverse Determinalli !t <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-87)R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />