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�DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> .�.. s• � roett- <br /> STATE SANITARY R\E RMIT#aC)g3 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than (j 1�, ) �`O <br /> 8'%x11inches insize. ❑ Check If revislodto 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 /> PAVC Q '/a ''/a,S T 0, N, R E (o W <br /> PRO ERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> oV t• La <br /> CITY,STATE ZIP CODE <br /> PHONE NUM ER SUBDIVISION NAME OR CSM NUMBER <br /> LEY) TJ 1 <br /> 11. TYPE OF UILDING: (Check one) CITU AREST ROAD <br /> gy�p7(( State Owned VILLAGE <br /> ❑ Public X 1 or 2 Fam.Dwelling-#of bedroomsL <br /> 111. 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 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 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 /> 11 F�J Seepage Bed 21 El Mound 30 ❑ Specify Type 41 El 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 13.AB RIP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROP SED(sq.a.) I (Gals/day/sq.a.) I (Min./inch) ELEVATION <br /> 3QQ Q , 612 1S 1 Q 7. 3 Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank <br /> Lia Pump TinWSi hon 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:( o S ps) MP/MPRSW No.: Business Phone Number: <br /> ((.VAf1 <br /> Plumber's Address(street,City,State,Zip Cod <br /> Z 3S 16L sygy <br /> IX. COUNTY/DEPARTMENT USE LY <br /> [—] Disapproved Sanitary Permit Fee Surcharge Fee) <br /> (includes Groundwater e e ssue Issuing Agen Ign re( St mps) <br /> I � V p <br /> Approved ❑ Owner Given Initial <br /> Adverse Determine.;-- <br /> e <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 />