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��ILH 1 SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STATE SANITARY P RMIT# 26 p I <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than („1q� oc /O`1 <br /> 8%x 11 inches in size. ❑Check If revisloh 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 OWNER PROPERTY LOCATION <br /> MtAESYa ''/a, S 3Z T N, R E (0 W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 3 <br /> CIN,STATE ZIP CODE PHONE NUMBER SU IVISION NAME OR CSM NUMBER <br /> CIRCLE PINE 0 6o go-88si <br /> It. TYPE OF BUILDING: (Check one) LJState Owned VILLAGE,ex m6 NEAREST ROAD <br /> ❑ Public 1 or 2 Fam.Dwellings of bedrooms_ <br /> III. BUILDING USE: (If building type is public,check all that apply) p-c1170-0 <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. TY F 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 /> 11Lyq Seepage Bed 21 ElMound 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 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.f.) PROPOSED(sq.ff.) (Gals/day/sq.ft.) (Min./inch) ELEVATION 3©o L <br /> Feet Feet <br /> CAPACITY <br /> VII. TANK in gallons Total III Prefab. Site Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdinci Tank <br /> Lift Pump Tank/Siphon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Pfill Plu ber's Signature:( o S ps) MP/MPRSW No.: Business Phone Number: <br /> Jo4m , PKl z r - 157 <br /> Plumber's Address(Street,City,State,Zip Codb): <br /> Z077G,0 tqwU6,6_5-raW l . 3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Age nt Si natur ( Stamps) <br /> Approved ❑ Owner Given Initial Surcharge Fee) <br /> Adverse Determinationl4o&co <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 />