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�ILHA SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code C UNTY <br /> urye4' <br /> STATE SANITARY�ERMIT#J.�G3rJ <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ /y.�Cr�.-rl <br /> 8'%x 11 inches in size. Cn if revisi to previous application <br /> -See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> P OPERTYOWNER PROPERTY LOCATION (` <br /> Oli M �..f1� �� YaS� '/4, S 'J T7� N, R 1 ' E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS / LOT# BLOCK N <br /> CITY, TATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> @x�✓I <br /> II. TYPE OF BUILDING: (Check one) CIN NEAREST ROAD <br /> State Owned VILLAGE <br /> ❑ Public X 1 or 2 Fam. Dwelling-#of bedrooms— A L NUM!lBERf( ) <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. %Replacement 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 IR 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 /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PER <br /> C.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REOIJIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) q i ELEVATION <br /> 3010 41lC) `f r 71 5--q-s- I -7 Feet ! 00 Feet <br /> VII. TANK CAPACITY Site <br /> in allona 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 /> Se tic Tank r H,IdInn Tank <br /> Lift Tank/Siphon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for'nstallation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plu is Si ature:( S ps) MP/MPRSW No.: Business Phone Number: <br /> Plum 's Address(StretlCity,State,Zip Code):7-,> s-Y-S�r_� <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I sanitffy Permit Fee (Includes Groundwatera e ssue Issuing Agent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial `�1� /�surcharge Fee) ](;� <br /> AdverseDetermination /"�W <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/98) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />