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�ILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> u,v ne <br /> STATE SANIT Y PERMIT#J 3 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ � � <br /> 8%x 11 inches in Size. eck If re inion 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 /> 5- -H h Ftn tLl'JeG Y4 't/a,S g4 T 40, N, R 114- <br /> PROPERTY <br /> 14PROPERTY O ER's MAILING ADDRESS LOT BLOC <br /> kV 5G CD _ nK# <br /> 1 q <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> oone_4- 1.L) IS148'0j `115 635- $p CSm VOL- 1 Q ?51 a 0v'+ LO+- to <br /> It. TYPE OF BUILDINfl: (Check one) 11 State Owned CITY <br /> LLLAGE NEAREST ROAD <br /> T��`j�_ `JCO CO. GL E <br /> ❑ Public or 2 Fam.Dwelling,#of bedrooms EL UMBER( <br /> Ill. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo <br /> 2$— IZ�}- - 08— ODO <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 rU 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 2.ABSORP.AREA 3.ABSORP.'AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 4 So (445 1048 0(09Feet Feet <br /> VII. TANK CAPACITY Site <br /> I n alloy Total #of Prefab. Fiber- Exper. <br /> INFORMATION New iln n Gallons of _ Manufacturer's Name oocyst Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank 1.0 001L 110o <br /> Lift Pum TenW pp <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the o9illite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature: No psi) MWMPRSW No.: Business Phone Number: <br /> Pr z '716-) 74FlZSLsCity,state, de): <br /> kA 51 fox 4193A 4SPooneAr. , sir at)I <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee (Includea Groundwater ae ssue Issuing Agent ' not mps) <br /> Approved ❑ Owner Given Initial Surcharge Feel n <br /> -Adverse Determination 13!5.oo <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />