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SANITARY PERMIT APPLICATION COUNTY <br /> 753ILHR In accord with ILHR 83.05,Wis.Adm.Code B RIS L [T— <br /> TE <br /> T —TE$ANITA PERMIT#I ij i3 L� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than (l/Ij 1 "--2)So I <br /> 8%x 11 inches in size. ❑ Cfieck If revis n to previous application <br /> -See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPE TY OWNER _ jPROPEqTY LOCATION <br /> AE k-f/a J�'/a, S� T � N, R 1(7E(or YCPROP RTYOWN,EB'SMAILING 9DDR SS # ' / BLOCK# <br /> I r i// 7CY1rf C fCITY STATE ZIP CODE / PHONE NUMBERDIVISION NAAfE Obi CSM NUMBER /�3`9 <br /> 1 L/4,9 a25 <br /> 21 <br /> II. TY E OF BUILDING: (Check one LJ VIILLAGE U /7i �/7/N/�EnARE$T ROA9 �P❑State OwnedILLAGE /,/ 0 (..❑ Public 1 or 2 Fam. Dwelling,#of bedroomPARCEL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) 3a <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. TY�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.El 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 El 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 13.ABSORP.AREA 14. LOADINGRATE 5. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> 3� REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> `� •5 Feet Feet <br /> VII. TANK CAPACITY site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrate Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding <br /> Lift Pum Tank/Siphon Chamber <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/MPRSS � Business Phone Number: <br /> e s 3 t59 731'' <br /> Plumb is Address(Street,City,State,Zip Code): <br /> .D ✓L t/e 5l er, (X-/1 5 W3 <br /> IY, COUNTYIDEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e esu lssvffigAgent Sigh re(No Stamps) <br /> A1 Surcharge Fee) <br /> Approved ❑ Owner Given Initial ,D /L� co //—�/ <br /> Adverse Det rmin tion <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />