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70ILHR SANITARY PERMIT APPLICATION COUNTY <br /> accord with ILHR 83.05,Wis.Adm.Code <br /> STATESANITARY ERMIT#)�03� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than C IS ']I I <br /> 8'%x11inches insize. ❑ Check It revision3o 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. <br /> PROPERTY OWNER PROPERTY LOCATION yy <br /> (C - 1 ) % ''/s, S b T �1, N, R (� E (o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVI ION AME OR CSM NUMBER <br /> II. TYPE OF BUILDING: Check one) CITY :3 R l� O NEAREST ROAD <br /> �ry ( ❑State Owned VILLAGE : Z yt 7> <br /> ❑ Public IL�J 1 or 2 Fam. Dwelling—#of bedrooms A !TIAANUMBI=R(bj <br /> t1 I< <br /> III. BUILDING USE: (If building type is public,check all that apply) 'a— / _?56 <br /> 1 ❑ ApVCOndo �J <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.'KReplacement 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 /> No�n�-.P,c/,essurized Distribution Pressurized Distribution Experimental Other <br /> 11 jLh�eepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 ���JJJJJ 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.ASSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gaya/day/sq.ft.) (Min./inch) _ ELEV TION <br /> 5 o c) O to `,JI, L_ J •r Feet Feet <br /> CAPACITY <br /> VII. TANK in allons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tankr- <br /> Lift Pump Tank/Siphon Chamber Vq <br /> Vlll. 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): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> oDE�(c(� t � ,,(� ®3a5 t S 66- 4161 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT U E ONLY <br /> Disapproved Sanitary Permit Fee(Includm Groundwater aessue ISSgl an Signa r No Stamps) <br /> Approved ElOwner Given Initial Surcharge Feel �xy� <br /> Adverse Determin onit <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-9399(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />