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7DILHR— m" SANITARY PERMIT APPLICATION c""In accord with ILHR 83.05,Wis.Adm.CodeuRtJ 1 ''n <br /> STATE%SANITARY-p1ERMIT#IgNq <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ / /5310/ <br /> 8'%x 11 inches in size. k Ir revisl6n 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 P P RTY LoCATION f <br /> V I \ rE L (/ ''/a /a, S T N, R 3 E(or nW <br /> PROPER OWNER'S MAILING ADDRESS OT# BLOCK# <br /> CLEV E u f . wT 198 <br /> CIT-Y,STATE I ZIP CODEPHONE NU B SUBDIVISION NAME OR CSM NUMBER <br /> dig <br /> It. TYPE OF BUILDING: (Check one) CITY N EST ROAD <br /> ❑State Owned " <br /> VILLAGE SQ� R . <br /> 1:1 Public 1 or 2 Fam. Dwelling-#of bedrooms, X u 655 K(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) r 3p�-5030- 0/_CDVO <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 Bit 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 ❑ Mound 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 4. LOADING RATE 5. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> S_ REQUIRED sq.ft.) PROPOSED sq.ft.) (Gals/day/sq.ft.) (Min./inch) q �r ELEVATION <br /> © (y ( , G Li I S. J Feet � 99Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name c ncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank ioocOC9C �-� <br /> Lift Pum Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT -TAW K <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 Sta ps) MPIMPRSW No.: Business Phone Number: <br /> Plumber's Address(Stree,City,State,Zip Code):- <br /> f�3sT>`JZ � <br /> IX. OUNTY/DEPARTME USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issugent Sig a(No Stamps) <br /> Approved ❑ Owner Given Initial 1 Surcharge Fee) <br /> Adverse Determination �Y– <br /> i n w C <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 />