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D1LHR SANITARY PERMIT APPLICATION <br /> Co T <br /> M s In accord with ILHR 83.05,Wis.Adm.Code <br /> ctcY Halal` <br /> • Y� SATESANITA) YPERMIT#kbeaj <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ❑ <br /> 8%x 11 inches in size. c klfre/I n 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.J S <br /> PROPERTY WNER PROPER LOCATION <br /> 144 ic G P CY '/4,SE'/a, S S� T , N, R Jq E(o W <br /> PROPERTY OWNER'S MAILIN ADDRESS LOT# BLOCK# <br /> I`. Ozr ` � <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 0 CITY <br /> It. TYPE OF ILDING: (Check one) ❑State Owned VILLAGE:V�Q�7 f10kY NEAR CRO . <br /> IN❑ Public 01 or 2 Fam. Dwelling-#of bedrooms A L AX Nu <br /> III. BUILDING USE: (If building type is public,check all that apply) <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.IgNBW 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 /> 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 /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Obi ELEVATION <br /> 300 © 0 612s- /7 7��Feet 0 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons of Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Se tic Tankor Holdin Tank .S^O 1 175-0 iP rrG e 13 1 L1_ <br /> Litt 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 /> Plumbbar's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> iVallate 'S. Ike SPn /`>P '7 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 6598 ,ke /�>! R , Ve J Lrr W SY?9.-7 <br /> IX. COUNTY/DEPARTMENT USE ONLr so <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwaterae ssue issuing A ent Signature tamps) <br /> Approved ❑ Owner Given Initial / ��tt77�� Surcharge Fee) d2 <br /> Adverse D t rmin tio <br /> n /as. vV /O 29 Ln "' <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6399(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />