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�DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY epi <br /> ll'- <br /> STATE/gANITARYYl��ERMIT <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ ( /b3y� <br /> 8%x 11 inches In size. check if revisio to 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 rr PROPERTY LOCATION cy <br /> IC u Q e SW11, 6ya, S �} 3 TN, R <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK It <br /> �S9Y� w B&S5 Ze Rd v`E• CcT3 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Wer, Uj I SV?9'3 7t -x',-70 <br /> 11. TYPE OF BUILDING: (Check one CITY NEAREST ROAD <br /> ❑ State Owned wt.uGE ePHBv� Q p <br /> El Public VV 1 or 2 Fam. Dwelling—#of bedrooms ) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) g_, a3- 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 ❑ 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. N 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 PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 4TV REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> / loin , b 6- 7- S- '7-1,3 Feet Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> e tic Tan rHoldin Tank _ <br /> ft <br /> Pum Ta Si hon Chamber O L <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility fok installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plu bar's Signature: os psi MP/MPRSW No.: Business Phone Number: <br /> IS r rw r IkIP S7F(I ( 71S-) <br /> lumber's Address(Street, ity,State,Zip Code): <br /> IX. OUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved San e Fee(includesGroundwaterrFeej water /a a �(xsyu� Issuing Age t ig'1 ( tamps) <br /> Approved Owner Given Initial U/`lJl " �" <br /> Adverse D t rmination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />