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70ILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITARY PERMIT#/3 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than (/Y7/ <br /> 8'%x 11 Inches in size. check if revisidoo 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. SSP - 0� 1 <br /> 2(41 <br /> PROP TY OWNER ZERAMTON <br /> S TV , N, RI�p E (orPROPE TY OWNER'S MAILING ADDRESSBLOCK# <br /> CITY STATE ZIPCODE PHONE NUMBER OR CSM NUMBER54II. TYPEOFBUILDING: (Checkone) CI N AREST RO D <br /> ❑ StateOwned a. <br /> e <br /> ❑ Public 1 or 2 Fam.Dwelling-#of bedrooms TAX NU ER( ) <br /> III. BUILDINGUSE: (If building type is public,check all that apply) `g',,,�� � <br /> a_ I _� <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.❑ 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 /> ( <br /> 11 ❑ Seepage Bed 21 ElMound 30 El SpecifyType 41 J�J Holding Tank <br /> 12 ❑ Seepage Trench 22 L1In-Ground42 Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PERDAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> _ M REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> l_�ill/YN) Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New is <br /> Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin 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 /> �1'mb%'s <br /> er's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSWW1No.: Business Phone Number: (� <br /> 1' 1 <br /> Ge/6 CJc�� - d" <br /> Address Street,City,State,Zip Code): <br /> V19 . <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(includes Groundwater a e IssuedIse n Agent Sign a(No Stamps) <br /> Surcharge Fee) /+ <br /> Approved ❑ Owner Given Initial cl}-ICS • CFO (/ �l./ <br /> Adv rmin {� / v <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />