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SANITARY PERMIT APPLICATION <br /> ILHR In accord with ILHR 83.05,Wis.Adm.Code couNn <br /> STATE SANITA PERMIT#h-3asqq <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ �y75y 7 I <br /> 8t%x 11 inches In size. eck if rev si n to previous application <br /> –See reverse side for Instructions for completing this application. STATE PLAN I. .NUMBER <br /> 1. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. <br /> PROPERTY,OWNER PROPERTYLOCATION <br /> E %W_I/a, S LI T Q N, R E (or W <br /> PROP RTY OWNER'S MAILING ADDRESS LOT# BLOCK <br /> CITY,STATE til ZIP CODE PHONE NUMBER SUBDIVISION NAMk OR CSM NUMBER <br /> Wes W C ol-5 /32 in - vt . tot -Q� <br /> 11. TYPE OF BUILDING: (Check one) CITY NE REST ROAD <br /> State Owned VILLAGE: ' S '- <br /> ❑ Public %1 or 2 Fam. Dwelling–#of bedrooms L OYMPNUM ( ) <br /> Ill. 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.X 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��Seepage Bed 21 El Mound 30 El Specify Type 41 El HoldingTank <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 5. PER' RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Mir clinch) �} ELEVATION <br /> '30a 2 r l `S .3 Feet .o Feet <br /> VII. TANK CAPACITY Site <br /> In allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New Iatin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanka Tanks structed <br /> Septic Tank or Holdin Tank <br /> Litt Pum Tank/Si hon 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 S ps) MP/MPRSW No.: Business Phone Number: <br /> b 01 f L6-46 <br /> Plumber's Add,(Street,City,Slat�Zip Code):_ <br /> bo <br /> IX. COUNTY/DEPART ENT USE ONLY <br /> Disapproved I Sanitary Permit Fee(Inclroudes Groundwater Date IssuedIss g Agent Signa r (No Stamps) <br /> 9 <br /> Approved ❑ Owner Adverse Determination <br /> /OS] Suhare Fee) <br /> Oc5 <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />