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SANITARY PERMIT APPLICATION <br /> ILHR In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STATE SANITARY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8'%x 11 inches in size. ❑ Check If 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 /> P PE RTY OWNER / /� PROPERTY LOCATION <br /> oo {,/4 Q - NEt/4&C'/4,S 1-' T3 7N, R -fc(or) W <br /> PROP TYOWNER'SM ING ADDRESS 6� y)-s LOT# BLOCK# <br /> C ,STATy ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> G: (Check one) CITY NEAREST ROAD <br /> 11. TYPE OF BUILDI <br /> State Owned O VILLAGE:121-TOWN OF: �oc� AUL' <br /> .45isel,4 /4 <br /> Public 1:11 or 2 Fam. Dwelling-#of bedrooms— PARCEL TAX NUM <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 YJ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4e 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 2/2�TReplacement 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 El Seepage Bed 21,r�suMound 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 /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIR D(aq.tt.) PROPO E (sq.ft.) ( als/da7y/sq.ft.) (Min./inch) `� 2 LEVATION <br /> ale `� I %L_ ( �i Feet � Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Hol dina Tank <br /> Lift Pump Tank/Siphon Chamber w <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for' tallation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(P ' / Plu bar' Signatur . mPe MP/M No.: Business Phone Number: <br /> u eve �e/"Uf 3/s S IT3 /7/__-3 <br /> Plumber's Address(Street, ity,State,zip ode): <br /> 0o w Ck a CA_ Es sY oI <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee(Includes Groundwater a eIssued Issuing Agent Signature(No Stamps) <br /> Surcharge Fee) <br /> ❑Approved E-1 Owner Given Initial <br /> Adverse Determination <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 />