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SANITARY PERMIT APPLICATION COGNTYb, <br /> 70ILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITARY PERMIT#)gs4s U <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 67ad-) <br /> 8%x 11 inches in size. 11 Check If r ion 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 PROPERTY LOCATION <br /> 1_y©iAt1 Au NNEK '/4 '/4,S 9 T V, N, R E(or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# __II / BLOCK# <br /> O _ 114 /3-1 1 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> If. TYPE OF BUILDING: (Check one) ❑State Owned El CITY Z J�TVILLAGE /`Q Ly1.1V] N sT VAD <br /> ❑ Public �1or2Fam. Dwelling-#ofbedrooms— VB r11�V��qq lV� <br /> III. BUILDING USE: (If building type is public,check all that apply) ao - 0S <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. eplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System ystem 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 /> 11Seepage Bed 21 ElMound 30 El SpecifyType 41 ElHolding Tank <br /> 12 X 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 PE7 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Mi ./inch) /`' ELEVATION <br /> 30° $� $� ' �� b-� Feet loci Feet <br /> CAPACITY <br /> VII. TANK in all '7 <br /> Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name ncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank <br /> Lift 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 /> Plumber's Name(Print): Plumber's Signature:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> ( ( �u/4WA - Z6 - I S1 <br /> PI mber's Address(Street,City,State,Zip Code): <br /> "Ll-400 w W <br /> IX.,COUNTY/DEPARTMENT US ONLY <br /> ❑ Disapproved Sanita Permit Fee(Includes Groundwater Date Issued Issuing Age Signa re(No S ps) <br /> Approved ❑ Owner Given Initial �-Surrccharge I") <br /> Adverse Determination t Co <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBO-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />