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aI&HR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> no STATE SA TARY PERMIT#a)�G)�i <br /> -Attach complete plans(to he county copy only)for the system,on paper not less than 17 <br /> 8'%x 11 inches in size. 1:1Chec If revision evious application <br /> —See reverse side for instirt ction3 for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROP TY OWNER PROPERTY LOCATION <br /> if F1LiJ 8 A tv '/s Sr-_ 1/ T �jo(, N, R �9 E(o <br /> PROPERTY OWNER'S AILINGA)DRESS LOT# BLOCK# <br /> CITY,STATE ' �!- ZIP CO E PHONE NUMBER { ' <br /> If. TYPE OF BUILDING: (Check one) JJ ✓ CITY /�p u'/1�'' NE[�REST ROAD <br /> ❑State Owned VILLAGE: MPRAAD !t+� O <br /> ❑ Public Y�.1 or 2 Fam.Dwelling-#of bedrooms / 1P�711 <br /> 111. BUILDING USE: (If building type is public,check all that apply) Ll C—3(0 L/3"-� D <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 Bit 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 Perm!,:was previously issued. Permit# �� Date Issued <br /> V. TYPE OF SYSTEM: (Ch k only one) <br /> Non-Pressurized Distribi,tion Pressurized Distribution Experimental Other <br /> 11Seepage Bed 21 ❑ Mound 30 El SpecifyType 41 ❑ Holding Tank <br /> 12 6 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' <br /> AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> RE ED AREA <br /> ft.) PRO ED(sq.ft.) (G Is/day/sq.ft.) (Min./inch) Q✓� C( ELEVATION <br /> 0� ( Z 3 1 I - U Feet 1M.3 Feet <br /> '10VII. TANK APACITY Site <br /> in al Ions Total #of Prefab. Fiber- Exper. <br /> INFORMATION New isfin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or HoldingTank <br /> Lift Pump Tank/Siphon Chamber ( ' <br /> Vlll. RESPONSIBILITY STATEN!ENT <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:INA Stamps) MP/MPRSWNo.: Business Phone Number: <br /> 1Gi RX19 <br /> Plumber's Address(Street,City,State,Zip Cod <br /> 27 bU 9yu 35 V 139mR W i - 548013 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved anitary Permit Fee(Includes Groundwater rDateIssued t Signat re(No Stamps) <br /> XApproved El Owner Give Surcharge Feel Initial dY IIT f� <br /> Adverse Determination <br /> �1A I—JlJ 1, <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/ 1 DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />