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�DILHR SANITARY PERMIT APPLICATION couNTY r� <br /> In accord with ILHR 83.05,Wis.Adm.CodeUI��- 1 <br /> �~ s• �_ STATE ANITARY 'ERMIT#/Z3 (4 � <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ ��C 7✓ <br /> 8%x 11 Inches In size. Check if rev! n to previous application <br /> -See reverse side for Instructions for Completing this application. STATE PLAN I.D.NUMBgER <br /> 50 <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. /- o� /O <br /> PROPERTY OWNER PROPERTY LOCATION <br /> / 'F1 6/ t/4 A t/4, S TqO, N, R to E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> q Q,C C PO &I #- ti' 14- <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 11. TYPE OF BUIL ING: (Check one CITY NEAREST ROAD <br /> ❑State Owned VILLAGE. }� <br /> Public ❑1 or 2 Fam. Dwelling-#of bedrooms— ELTAx uMBE /^ <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 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 �Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 El 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 /> 11eepage Bed 21 ElMound 30 ElSpecify Type 41 ❑ Holding Tank <br /> 12 gleepagp 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 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED( ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) / ,r ELEY/AATIgN <br /> 3 3 ( Q I .3P 1 3 9(O-Feet ."rC Feet <br /> VII. TANK CA ACISite <br /> TY <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrate Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or HoldinTank W Z <br /> Lift Pum Tank/SI hon Chamber LUL <br /> VIII. RESPONSIBILITY STATEMENT M4%>7L <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plug's Name(Print): Plum,patas4iguature,(I Stam MP/MPRSW No.: Business Phone Number: <br /> 2 IN <br /> Plumber's Address(Street,City,State,Zip Code): <br /> h'Td. to 7"/ (7i` - 5`Y e 3 n <br /> IX. OUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(includes Groundwater a e ssue Issuing,A e Sign ure( o Stamps) <br /> LApprovedSurcharge Fee) �—J❑ Owner Given Initial -� � <br /> Averse De r-r <br /> rmin tion --� ° D <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 />