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LHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code a�. U—rA e.� <br /> 17O <br /> =.....,..,a. SSTTEFANIT_ARY PWIVII I IF <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than k ilfTlreC�visTi/7oe/n0lIpreviotua application <br /> 8%x 11 Inches In size. STATE PLAN .D.NUMBER <br /> —See reverse side for instructions for completing this application. 1:7 p�j_ �O <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. D 1 <br /> PROPERTY OWNER PROPERTY LOCATION W <br /> ����„� rn g5J.I % svi %,s ao rLFo, N, R 14 <br /> LOT# 1 BLOCK# <br /> PROPERTY OWNER'S MAILING ADDRESS ,o R <br /> I'Z * I ax an.8 <br /> CITY,STATE ,n/1 ZIP CODE PHONE NUMBER SUBDIVISI_ ON NAME OR CSM NUMBER ^ <br /> tnC.r�` ' ' rA 5503-7 /YJ_ NE,A/REST ROAD <br /> Cm <br /> 11. TYPE OF B ILDING: (Check one) ❑ State Owned VILLAGE WIN . �O� O q K LAKE <br /> ❑ Public ®1 or 2 Fam.Dwelling-#of bedrooms�— AR ELT NUMBER(5) <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo 10 ❑ Outdoor Recreational Facility <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 11 ❑ Restaurant/Bar/Dining <br /> 3 Campground 7 ❑ Merchandise: Sales/Repairs 12 ❑ Service Station/Car Wash <br /> 4 ElChurch/School 8 ❑ Mobile Home Park <br /> 5 ❑ Hotel/Motel <br /> 9 ❑ Office/Factory 13 ❑ Other: Speciry <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> ❑ Repair of an <br /> A) 1. ® New 2. ❑ Replacement 3. ❑ Replacement of 4 ❑ Reconnection <br /> System 5 Existing System <br /> System System Tank Only 9 y <br /> B) ❑ A Sanitary Permit was previously issued. Permit# — <br /> Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental <br /> Other <br /> 21 ❑ Mound 30 ❑ Specify Type 41 ® Holding Tank <br /> 11 ❑ Seepage Bed 42 ❑ Pit Privy <br /> 12 ❑ Seepage Trench 22 ❑ In-Ground 43 ❑ Vault Privy <br /> 13 ❑ Seepage Pit Pressure <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: FIN <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. (M C:RATE 6. SYSTEM ELEV. 7. ELEVATION GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (G A.1 <br /> ft.) (N'/ IA <br /> h) ^/ �} Feet Feet <br /> Soo tJ/A, A �L/ A <br /> CAPACITY Prefab. SiteEx er. <br /> VII. TANK in allons Total #of Manufacturer's Name Con- Steel Fll er Plastic APp <br /> INFORMATION New istin Gallons Tanks oncrete structed g <br /> Tanks Tanks <br /> Se tic Tank or Holdin Tank <br /> poo 00 ojrre ✓ <br /> Lift Pum Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsit swage system shown on the attached plans. <br /> Plumber's Name(Print): lumber's Signature:( Sts a) <br /> MP/MPRSW No.: Business Phone Number: <br /> C 333 '718 b3�7S5S <br /> Plum er's Address(Street,QW,State,Zip Code): S`/DO/ <br /> O o rLa✓ LL)11 <br /> 7 0 <br /> IX. COUNTYIDEPARTMENT USE ONLY ISanln A nt Signature(No Stamps) <br /> Disapproved Diss Sanitary Permit Fee(Incluaee Groundwater [Dateissued9 <br /> p surcharge Fee) /y1 � <br /> Approved ❑ owner Given Initial <br /> A verse Det rmin tion <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />