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�DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTY e44- <br /> STATE/Sq���l ITARY ERMIT#/S/`- <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than l / /V j <br /> 8'%x 11 inches in size. ❑ Check if revisi 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 /> PROPERTY OWNER PROPERTY L ATION <br /> T6 tv\. o-4a_ 2_ 56 %5i %, S -7e MAR R /S-E-Ma) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 1 a o �(o�� AV-,- M . 7 <br /> CITY,STATE ZIP CODE 1PHONENUMBER SUBDIVI ION NAME OR CSM NUMBER <br /> IM-o- 1M SSgq �_-/a 5S3O)3 <br /> If. TYPE OF BUILDING: (Check one CITY NEAREST ROAD p / <br /> �7I ) State Owned VILLAGE:S �' �-Rtd Z�P ICO2� <br /> ❑ Public N 1 or 2 Fam. Dwelling-#of bedrooms OAKUhL I AX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) <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 <br /> II OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. IDI 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 /> 11Seepage Bed 21 ❑ Mound 30 EJSpecify 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 12.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED <br /> (sq.ft.) PROPOSED(sq.tt.) (Gals/day/sq.ft.) (Min./inch) /' pELEVATION <br /> 1J 11 <br /> 3a 1� �-� - 3 / Feet / Feet <br /> VII. TANK CAPACITY Site <br /> INFORMATION in gallons Total #of Prefab. Fiber- Exper. <br /> New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic A <br /> Tanks Tanka strutted pp' <br /> tic Ta or Holdina Tank 00 vJ LA)( esff- C <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): PIu er's Si natur (N tamps) MP/MPRSW No.: Business Phone Number: <br /> e(S Koev v' 1Vl`PS�SLf !S Y&Cn Xcg' <br /> Plumber's Ad ass(Street,City,State,Zip Code): � { <br /> S C e kS e W I% J <br /> IX. COUNTYIDEPARTMEWT USE ONLY <br /> Ej Disapproved Sanitary Permit Fee(Includes Groundwater Datessue Issuing gent Signature(No Stamps) <br /> XApproved ❑ Owner Given Initial �c) ��,p7S-urcharge Fee) <br /> Adverse Determination Ov ' cc � ��1 t I "V ' ' r•"""2 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />