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1LHR SANITARY PERMIT APPLICATION <br /> 7.M„ Hq In accord with ILHR 83.05,Wis.Adm.Code couNTv�ur <br /> STATE SANITARKPERMIT#�gSSa3 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ hec170 7�) <br /> 8'%x 11 inches in size. <br /> kifrev' ion 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 /> PROPERTY OWNER LPROPERTYNc L S 3z- T �0 , N, R f(o E (o WPRP OWNER'S MAILING ADDRESS BLOCK# hCITY,STATE ZIP CODE PHONE NUMBER OR CSM NUMBERsMN II. TYPE OF BUILDING: (Check one) NEAREST R D <br /> State owned /(SUM0 ST. <br /> ❑ Public ®1 or 2 Fam.Dwelling-#of bedrooms 1.. 11 <br /> Ill. BUILDING USE: (If building type is public,check all that apply) gwas-c)4-7ao <br /> 1 ❑ ApVCondo <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) 1.1� 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 /> 1 1,XSeepage Bed 21 ❑ Mound 30 ❑ SpeciyType 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 2SORP.AREA 3.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> ZO Zb 1r Z. 3 9`1-5 Feet 91.0 Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Expp. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name c ncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdino Tank <br /> Litt Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:(No ps) MP/MPRSW No.: Business Phone Number: <br /> i0ko K/ S 3yz� l5 66- IS7 <br /> lumber's Address(Street,City,State,Zip Code): <br /> Z foo w W EBSTC LJ <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E) Disapproved Sanitary Permit Fee(Includes Groundwater a e issue Issuing A n igne re IN mps) <br /> Approved ❑ owner Given Initial �r-Surcharge Fee) _C <br /> Adverse Determination J ��Jr-� 'CC) <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)F.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />