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17- mmm%DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.CodeJ, <br /> �~ s• momms� STATE 1NIITTAARYPERMIT# 13gQI8 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than (15WI ) <br /> 8'%x 11 inches in size. ❑ Check If revla(on 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 ZPRIPIERTY L ATION <br /> ME CURM a{ U U N ''/a5 ''/a,S (Z- T��, N, R E (OkW <br /> PROPERTY OWNER'S AILING ADDRESS n BLOCK# <br /> CITY,STATE ( ZIP CODE PHON NUMBER- IVI IQN NAME OR CSM NUMBER <br /> Ul tLl1c-FILS <br /> ILDING: (Check one) TY NEAREST ROAD <br /> may{ ❑State OwnedLLAGE (OK Rp- <br /> ❑ Public ,l�I 1 or 2 Fam.Dwelling,#of bedrooms Ax Nu R( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) — �/��o�—U� - CR l-L�qqrr,� <br /> .' <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. ❑ Replacement 3. ElReplacement 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- <br /> Prressurized 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 /> V1. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. FERC,RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 2� REQUIRED(s 1.ft.) PROPOSED(sq.ft.) (Gal//s/d /sq.ft.) (Min./inch) ELEVATION <br /> _No tP1:4J-� Feet I q 53.0Feet <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 Holdkn Tank �� <br /> Lift Pum Tank/Si 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:(No Sta ps) MP/MPRSW No.: Business Phone Number: <br /> iWKIMS <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 'Zl71l Hw4 3S wlEi7>5Za, li.)1 GH<got_�3 <br /> IX, COUNTYIDEPARTM NT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Is in Agent Signat Stamps) <br /> ,y., Surcharge Fee) <br /> Approved ❑ Owner Given Initial �}{, 'OS,/�� <br /> Adverse Deter in i n —H vv <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBO-6398(formerly Pil(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />