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=0ILHA SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couNTv <br /> STATE SPITARY P MIT#1 ' 3q <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ( j5C,977 <br /> 8'%x 11 inches in size. ❑ CheZk�if revision-a5previous application <br /> –See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. I Zal —7. <br /> PROPERTY OWNERpk�10PERTY OCATION <br /> R LEMorJ E ''/a, S Zb T h N, R E(or WPROPERT`(O NE R's MAILINGAPIRESS - RQ ' I2 GBL/OC�K QUJTlE LC•{/� YZI�P�C0DEPHONE NUMBER MAN E GR 88M PIWM96R <br /> W (2":5 V III. TYPE OF BUILDING: Check one) NEARE ROAD <br /> ( State OWned 0 r; , O f] <br /> ❑ Public .N 1 or 2 Fam. Dwelling–#of bedrooms— PA L R( ) l V t l <br /> Ill. BUILDING USE: (If building type is public,check all that apply) A – q 1 ao '0/—3i0 <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. ❑ 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 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROOPOO§ED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 2 T 1 LJ�L1 , Z d Feet Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks I Tanks c structed <br /> Septic Tank or HoldingTank w17 E '� <br /> Lift Pum Tank/Siphon Chamber CAMbI <br /> VIII. RESPONSIBILITY STATEME T <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> plimPI mber's Name(Prin : PI bar's Signatu e:IN Stamps) MP/MPRSW No.: Business Phone Number: <br /> IC ARD DPKj�! <br /> lumber's Address(St t,City,State,Zi Cod ): <br /> "1(0 W WE$51OZ <br /> OUNTY/DEPARTME T USE ONLY <br /> ❑ Disapproved SanitaryPermit Fee(includes Groundwater ae ssu Issuin Agent Sign oo�Stamps) <br /> Approved ❑ owner Given Initial / Jsuurrcharge Fee) /� ' U <br /> Adverse Determination ! �/ JL, `ti,��,6/ <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 />