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DiLHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code _ S I <br /> mm STATE SANITA Y PERMIT <br /> —Attach complete plans(to It e county copy only)for the system,on paper not less than IBS <br /> 8%x 11 inches in size. ❑ Check If revision to previous application <br /> —See reverse side for instru tions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATI N—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION U ,//J <br /> Pp IVF,- %A/Z'%, S C1�� T /a N, R vQ )W <br /> PROPERTY OWNER'S MAILING A[DRESS LOT# BLOCK# <br /> 12D - <br /> CITY,STATE IP CODE PHONE NU BER SUBDIVISION NAME OR CSM NUMBER <br /> J ) . $ 3 S 6 2 <br /> 0 CITY <br /> II. TYPE OF BUILDI <br /> �ING: (Ch ck one) ❑State Owned VILLAGE 0)9NEARES ti R&LvOAD <br /> —] Public ASI1 ort am. Dwellingof bedrooms A L <br /> III. BUILDING USE: (If buildi ig type is public,check all that apply) <br /> 1 ❑ Apt/Condo V v <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: (Ch k only one in line A. Check line <br /> line B if applicable) <br /> A) 1. ❑ New 2. Replacement 3. IL` Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) 0 A Sanitary Permit was previously issued. Permit# 16� Date Issued <br /> V. TYPE OF SYSTEM: (Cht ck only one) <br /> Non-Pressurized Distribu ion Pressurized Distribution Experimental Other <br /> 11Seepage Bed 21 ElMound 30 ❑ Specify Type 41 ElHolding Tank <br /> 12 N Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEMINFORMATION: (,STT Tj 6 <br /> 1.GALLONS PER 51 2.AE ISORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 17, FINAI <br /> GRADE <br /> REO IRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 3�oI I I I Feet Feet <br /> VII. TANK CAPACITY Site <br /> L <br /> all ns Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STA EMENT <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 Stamps) MP/MPRSW No.: Business Phone Number: <br /> i 01§ - 15 <br /> Plumber's Address(street,city,8 ate,Zip Code. <br /> 6O 5 GJ�ssf S` 3 <br /> IX. COUNTY/DEPARTMENT US ONLY <br /> ❑ Disapprove4 Sanitary Permit Fee(Includes Groundwater a e Issued Issu g gent Sig t r IN Stamps) <br /> �I ' Surcharge Fee) <br /> Lry.Approved ❑ Owner Give Initial .'_surcharge <br /> Advers Drmination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11,181") DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />