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SANITARY PERMIT APPLICATION n accord COUNTY(1� <br /> ©ILHR In with ILHR 83.05,Wis.Adm.Code ,r <br /> moomma <br /> �•�_� STATE SANITARY PERMIT# (32S`o3 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ( f u'I'LlS ) <br /> 8'%x 11 inches In size. ❑ Check it revision 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 i! OWNER PROPERTY LOCATION <br /> T L��/N� (— -'X Ya, S 17 T y4 N, R /6 E (or <br /> PROPERTY OWNER'S MAILING/ ` ADDRESS LOT# BLOCK# <br /> /0 916 <br /> CITY,STATE l/ !`GC/ ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER CSM <br /> � ,^ � �®�� <br /> l�l� sZ ftp! $`f3 Sr ?Z C...J U <br /> If. TYPE OF BUILDING: (Check one) State Owned CITY VILLAGE ,LJ NEAREST ROAD <br /> ❑ / <br /> ❑ Public 1 L <br /> or 2 Fam. Dwelling-#of bedrooms L NUM ( ) <br /> III. BUILDING USE: (if building type is public,check all that apply) X _q3a D -0& —9Q0 <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. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System ystem 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 ElSpecify 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 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.� PROPOSED(sq.ft.) (Gals/day/sq.ft.) I (Min./inch) / o- ELEVATION <br /> SO • ?3 ,� - Feet -' Feet <br /> VII. TANK APACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istln Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdin Tank ` k4` <br /> LIR Pum Tank/SI hon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plu r'a Name(Print): Plum s Si n re:(No fe ) MP/MPRSW No.: Business Phone Number: <br /> M9N = ol�� 3o7a— 9�i 2-V3)W <br /> Plumber's Address(Street,City,State,Zip code): <br /> g70 S e�P30 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> El Disapproved Sanitary Permit Fee(Includes Groundwater [Date Issued Is Agent SI tura(No Stamps) <br /> roved owner Given Initial Surcharge Fee) <br /> pp �`��- <br /> Adverse in tl n <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 />